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C H I C AC  O 


VISITING  NURSE  MANUAL 


PREPARED  FOR 

THE  VISITING  NURSE  ASSOCIATION  OF  CHICAGO 
AND  OTHER  PUBLIC  HEALTH  NURSES 

By  EDNA  L.  FOLEY , R.  N. 


PUBLISHED  UNDER  THE  AUSPICES  OF 

THE  NATIONAL  ORGANIZATION  FOR  PUBLIC  HEALTH  NURSING 

BY 


THE  VISITING  NURSE  ASSOCIATION  OF  CHICAGO 
104  S.  Michigan  Avenue 

1914 


Digitized  by  the  Internet  Archive 
in  2017  with  funding  from 

University  of  Illinois  Urbana-Champaign  Alternates 


https://archive.org/details/visitingnursemanOOfole 


INTRODUCTION 


The  object  of  the  Visiting  Nurse  Association  of 
Chicago  is,  first,  to  give  skilled  nursing  care  to  the 
sick  in  their  homes;  second,  to  teach  personal  hygiene, 
cleanliness,  and  the  prevention  of  disease. 

No  calls  are  made  outside  the  city  limits. 

The  following  directions  are  intended  to  serve  as  a 
guide  to  new  nurses  and  as  a manual  of  reference  for 
all  the  staff  nurses. 

As  visiting  nursing  implies  that  the  patient  will  be 
seen  probably  once  or  at  most  only  twice  during  the 
day  by  the  nurse,  some  care  must  be  given  between 
visits;  therefore  the  word  “attendant,”  used  so  con- 
stantly throughout  the  book,  is  meant  to  indicate  the 
person  (mother,  husband,  daughter  or  neighbor)  to 
whom  instructions  for  the  patient's  care  are  given. 

Not  all  problems  can  be  foreseen  and  covered  by  the 
following  rules.  When  in  doubt,  the  Main  Office  should 
be  consulted  in  emergency;  the  advice  of  the  Supervisor 
may  be  sought  at  noon  or  night.  Consultation  is  better 
than  hasty  judgment. 

The  visiting  nurse  should  remember  that  she  is  not 
an  isolated  unit  giving  nursing  care  in  various  homes, 
but  the  trusted  representative  of  the  Visiting  Nurse 
Association  of  Chicago.  Her  uniform  implies  trained 
skill,  intelligence  and  authority.  When  wearing  it,  she 
is  the  paid  agent  of  citizens  whose  liberality  enables  her 
to  give  this  skill  and  training  to  people  unable  to  pro- 
vide it  for  themselves. 


GENERAL  INSTRUCTIONS. 

Daily  Routine.  Hours  of  duty  are  from  8:30  a.  m.  to 
5 p.  m.,  with  one  hour  for  lunch  at  noon.  Each  district 
nurse  should  be  in  the  home  of  her  first  patient  at  8:30 
a.  m. 

Absences  should  be  telephoned  to  Supervisors  before 
7 a.  m.  If  for  any  reason  the  Supervisor  cannot  be 
reached,  the  Superintendent  should  be  notified.  This 
will  ensure  nursing  care  to  all  patients  in  the  district  of 
an  absent  nurse. 

Visitors  may  not  be  taken  into  the  homes  of  patients 
except  by  permission  from  the  Main  Office. 

Plan  for  the  Day.  New  calls  received  over  night,  all 
clean  cases  requiring  care  (delivered  maternities,  non- 
contagious,  acutely  ill,  clean  dressings,  etc.)  should  be 
seen  in  the  morning  in  the  order  of  their  need,  thus 
leaving  the  afternoon  free  for  new  calls,  instructive 
visits  and  general  emergency  work. 

Nurses  should  not  promise  to  meet  physicians  or 
other  workers  in  patients’  homes  by  appointments,  for  a 
visiting  nurse’s  day,  no  matter  how  carefully  planned, 
is  always  subject  to  unavoidable  delays  and  interrup- 
tions. As  a rule,  hospital  and  dispensary  appointments 
can  be  kept. 

By  careful  planning,  it  may  be  possible  to  make  calls 
to  some  patients  at  the  same  hours  daily,  but  it  is  best 
to  warn  these  patients  that  emergencies  may  arise  to 
interfere  with  such  a daily  program. 

Number  of  Daily  Calls.  Nine  is  the  average  number 
of  calls  made  daily  in  a Chicago  district.  In  the  smaller 
districts  where  many  families  live  under  one  roof,  it  is 
possible  to  make  from  twelve  to  fourteen  calls  daily; 
whereas  in  the  more  scattered  prairie  districts  six  to 
eight  is  a fair  average. 

Nursing  Calls  (other  than  T.  P.  R.  only  calls)  require 
from  one-half  hour  to  an  hour.  General  nursing  care 


General  Instructions  9 

requires  from  45  minutes  to  one  hour.  A few  calls  need 
more  time. 

Instructive  Visits  are  as  important  and  should  be  as 
carefully  made  as  nursing  visits.  They  should  never  be 
hurried. 

Frequency  of  Calls. 

1.  All  chronics  at  least  once  weekly. 

2.  All  varicose  ulcers  daily,  or  as  indicated. 

3.  All  surgical  dressings  daily  unless  otherwise 

ordered. 

4.  Bed-ridden  tuberculosis  cases  daily  or  every 

second  day. 

5.  All  maternity  cases  daily  for  the  first  ten  days, 

then  every  second  day  until  the  mother  is  up 

and  able  to  care  for  the  baby. 

6.  New-born  infants  daily  until  cord  is  off  and 

stump  healed. 

7.  All  acutely  ill  patients  daily. 

8.  All  acute  and  critically  - ill  patients  running 

temperatures  or  requiring  change  of  dress- 
ing, twice  daily. 

9.  All  “special  nurse”  cases  every  second  day. 

10.  Never  forward  a patient  without  at  least  one 

monthly  visit. 

11.  Instructive  visits,  frequently,  until  teaching  is 

understood,  then  occasionally,  to  encourage 

and  supervise. 

Sunday  Calls.  New  maternity  cases  for  whom  no 
other  care  is  provided,  critically  ill  acute  cases,  and 
surgical  dressings  that  cannot  be  left  from  Saturday 
afternoon  to  Monday  morning,  require  Sunday  calls. 
Plan  to  see  your  most  urgent  cases  late  Saturday  and 
early  Monday. 

District.  A district  is  the  amount  of  territory  allot- 
ted each  nurse.  Districts  are  usually  planned  according 
to  both  population  and  area.  Small  districts  are  the 
rule  in  very  congested  parts  of  a city;  large  districts 


10 


Visiting  Nurse  Manual 


cover  the  outlying  territories  where  the  population  is 
scattered,  or  not  of  the  type  requiring  hourly  or 
visiting  nurse  service. 

A nurse  in  charge  of  a district  is  responsible  to  her 
Supervisor,  to  the  Superintendent  of  the  Association, 
and  to  the  Board  of  Directors,  for  all  work  (nursing, 
instructive  and  clerical)  done  in  that  particular  terri- 
tory. 

Map  of  District.  The  boundary  lines  of  every  district 
are  plainly  marked  in  the  district  time  book  and  on  the 
maps  at  the  substations.  Each  district  includes  the 
cases  on  its  north  and  east  boundary  lines.  The  map 
of  a district,  cut  from  the  map  in  the  guide  book,  and 
pasted  on  heavy  paper,  is  indispensable  to  a new  nurse. 
By  planning  the  work  according  to  the  geography  of  the 
district,  keeping  in  mind  the  best  transportation  lines 
and  transfer  points,  a new  district  soon  becomes  famil- 
iar territory.  Chicago  streets  and  distances  are  easily 
learned. 

East  refers  to  all  numbers  east  of  State  street. 

West  refers  to  all  numbers  west  of  State  street. 

North  refers  to  all  numbers  north  of  Madison  street. 

South  refers  to  all  numbers  south  of  Madison  street. 

Eight  hundred  numbers  equal  one  mile. 

No.  1 of  every  street  begins  either  at  State  or  Madi- 
son. Odd  numbers  fall  on  the  east  and  south  sides  of 
every  street.  A careful  study  of  a map  of  the  city  will 
make  the  daily  routine  much  simpler.  A district  should 
be  studied  by  street  numbers  as  well  as  by  street  names. 

Nationalities,  conditions,  circumstances,  vary  widely 
in  each  district.  A nurse  must  be  alert  to  sense  these 
differences.  There  is  no  one  more  respected  and  beloved 
in  these  districts  than  a good  visiting  nurse  whose 
desire  to  serve  her  patients  is  tempered  with  a wise 
sympathy  and  common-sense. 

New  Calls  will  be  telephoned  to  the  substations  before 
1:30  p.  m.  and  to  the  nurses’  homes  after  4:30  p.  m. 

Addresses.  In  taking  or  giving  addresses  over  the 
telephone,  repeat  the  number  carefully,  ascertain  the 


General  Instructions 


11 


part  of  the  house,  if  east  or  west,  north  or  south, 
street  or  place,  diagnosis,  doctor's  name,  and  name  and 
telephone  number  of  person  referring  call.  This  last 
helps  in  tracing  incorrect  addresses. 

Wrong  Addresses.  If  an  address  from  the  Main  Office 
is  inaccurate,  telephone  the  office  for  correction.  If 
the  call  was  received  from  the  substation,  no  correction 
can  be  obtained  until  the  Supervisor  can  be  reached  by 
telephone.  Always  report  wrong  addresses  at  the  ear- 
liest possible  moment.  Never  wait  until  the  following 
noon  to  do  this.  If  the  case  was  reported  as  urgent, 
report  to  the  Main  Office  for  further  instructions.  All 
wrong  addresses  not  sent  out  from  the  Main  Office 
should  be  reported  to  the  Supervisor  in  the  evening,  or, 
if  a morning  call,  at  noon.  Incorrect  Metropolitan  Life 
Insurance  Company  addresses  should  be  reported  to  the 
Supervisor  in  the  same  way.  Corrections  of  these  must 
be  obtained  from  the  insurance  agent  by  the  nurse 
making  a daily  visit  to  the  Metropolitan  office. 

Calls  Out  of  District.  If  asked  to  make  a call  outside 
of  your  district  take  the  name,  address  and  facts,  and 
telephone  these  to  the  Main  Office  or  report  to  the 
Supervisor  at  noon.  If  an  emergency  call  but  a few 
blocks  out  of  your  district,  make  the  call  yourself  and 
then  report  to  the  Main  Office. 

New  Patients  should  be  seen  as  early  during  the  half- 
day following  receipt  of  the  call  as  possible.  This  is  to 
insure  prompt  care  to  all  very  ill  and  to  emergency 
patients.  New  calls  not  made  promptly  and  new  pa- 
tients not  found  at  home  should  be  reported  to  Super- 
visor at  night  or  at  noon. 


SUPPLIES. 

Uniforms.  The  out-door  uniform  (hat,  coat  and  bag) 
is  the  property  of  the  Association.  The  prescribed 
dress,  blue  chambray,  with  detachable  cuffs  and  collars 
(Bishop  or  Eton  cut)  of  white  pique  are  supplied  by 
each  nurse.  The  pin  and  arm-bands  are  loaned  by  the 
Association.  Jewelry  should  not  be  worn. 

Probably  three-fourths  of  a visiting  nursed  day  is 
spent  walking  or  standing,  therefore  the  kind  of  shoes 
worn  is  very  important.  No  special  shoe  is  prescribed; 
but  thick-soled,  well-cut  high  shoes  are  advised.  After 
much  unaccustomed  walking,  the  feet  may  be  tempor- 
arily enlarged,  another  reason  for  wearing  comfortable, 
well-selected  shoes.  Tired  or  burning  feet  should  be 
bathed  (not  soaked)  at  night  in  cold  water  to  which 
alcohol  or  an  astringent  has  been  added,  and  afterwards 
well  powdered  with  boracic. 

Car  Tickets  are  given  each  nurse  on  her  first  morn- 
ing. Every  ticket  costs  the  Association  5 cents.  Tickets 
should  be  carefully  handled,  and  an  exact  accounting  of 
the  number  used  should  be  written  on  the  daily  report. 
Never  fail  to  ask  for  transfers.  In  Chicago  passengers 
may  ride  repeatedly  on  transfers  within  certain  time 
limits  if  the  direction  of  travel  is  not  retraced. 

Car  Ticket  Requisitions  (0.  K’d  by  Supervisor)  must 
be  in  the  Main  Office  by  Saturday  noon  of  each  week. 

Cash  Accounts.  All  money  used  for  telephoning  and 
supplies  for  patients  should  be  recorded  on  the  daily  re- 
port, and  on  the  18th  of  each  month  a statement  of  such 
expenditures  should  be  written  and  given  to  the  Super- 
visor. This  amount,  if  0.  KM  by  the  Supervisor,  is 
added  to  the  salary  check. 

A watch  with  hour  and  minute  hands  and  a fountain 
pen,  the  property  of  each  nurse,  should  always  be  in 
good  repair. 

Visiting  Nurse  Bags  are  lined  with  rubber  and  a 


Supplies 


13 


removable  cotton  lining.  This  latter  should  be  changed 
twice  weekly.  The  rubber  should  be  scrubbed  at  least 
once  a week.  A well-kept  bag  is  a fair  index  of  the 
ability  of  a visiting  nurse.  Each  bag  is  provided  with: 

One  fountain  syringe  (to  be  sterilized  before  using  in 
clean  cases)  in  a white  cotton  bag. 

One  dressing  basin,  in  white  cotton  bag. 

Gauze  and  bandages,  in  white  cotton  bag. 

Absorbent  cotton,  in  white  cotton  bag. 

Instrument  case  containing 

Silver  probe,  Glass  piston  syringe, 

Forceps  (artery  and  Glass  douche  point, 


dressing), 
Dressing  scissors, 
Glass  catheter, 
Rubber  catheter, 


Glass  enema  point, 
Medicine  dropper, 
Nail  file, 

Spatula. 


Three  thermometers  (mouth,  rectal  and  emergency) 
carefully  labeled. 

Two-ounce  bottles  containing 
Lysol,  Alcohol, 

Olive  oil,  Boric  powder, 

Boric  crystals. 

(These  bottles  should  be  plainly  labeled  and  relabeled, 
P.  R.  N.) 

Ointment  tins,  containing 
Zinc  oxide  ointment, 

Vaseline, 

Green  soap. 


Also, 

Tongue  depressors  (wrapped  in  paper), 

Short  strips  of  adhesive  wound  on  tongue  depressor, 
Dressing  towel, 

Hand  towel,  nail  brush  and  soap  in  rubber-lined  bag, 
Common  scissors, 

Metal  comb, 

Apron  (of  white  cotton  crepe). 

Bags  will  be  inspected  monthly  or  oftener. 

New  equipment  may  be  obtained  from  Supervisor 
only  when  old  articles  are  returned. 


14 


Visiting  Nurse  Manual 


Hypodermic  Syringe  may  always  be  obtained  at  the 
substation.  Before  giving  subcutaneous  injections,  boil 
the  needle,  sterilize  the  barrel  with  alcholol,  and  cleanse 
the  site  of  insertion  with  alcohol. 

Miscellaneous  Supplies.  Linen,  rubber  goods,  sick- 
room utensils,  etc.,  may  be  obtained  from  the  substation 
loan  closet. 

Thermometers.  Mouth  thermometers  should  be 
cleaned  by  being  wiped  with  cotton  saturated  in  alcohol 
before  and  after  using,  then  washed  in  clean  water; 
rectal  thermometers  with  cotton  saturated  with  lysol, 
then  washed  in  clean  water. 

A thermometer  used  by  patients  suffering  from  any 
communicable  disease  (typhoid,  tuberculosis,  diphtheria, 
scarlet  fever,  etc.)  should  be  entirely  immersed  in  a two 
per  cent  lysol  solution  while  care  is  being  given  patient, 
then  thoroughly  washed  in  fresh  water  before  being 
returned  to  case.  Thermometers,  dressing  forceps,  or 
scissors  should  never  be  dipped  in  alcohol  or  lysol 
bottles. 

Never  leave  a thermometer  in  a tumbler  of  any  solu- 
tion, poisonous  or  otherwise,  for  a despondent  patient 
or  a child  may  drink  the  solution  and  alarm  the  entire 
family,  if  no  more  serious  harm  is  done.  Teach  the 
patient  to  cleanse  his  own  thermometer  carefully,  to 
dry  it  and  to  put  it  in  the  case  or  in  a safe  place. 

Rubber  Gloves  will  be  kept  at  the  substation  and  may 
be  left  in  the  homes  whenever  necessary.  Gloves  should 
be  worn  for  all  extensive,  profusely  discharging  dress- 
ings, both  for  the  protection  of  the  nurse  and  to  pre- 
vent any  cross  infection.  After  using,  gloves  should  be 
thoroughly  washed,  sterilized,  dried  and  powdered. 
When  necessary,  gloves  may  be  left  in  the  homes  until 
the  case  is  terminated.  No  one  pair  of  gloves  should 
be  used  on  two  bad  septic  cases  consecutively. 

All  gloves  returned  to  the  substations  should  be  given 
to  the  Supervisor  and  their  previous  use  explained.  In 
some  cases  it  is  better  to  destroy  gloves  than  to  return 
them  to  the  supply  closet,  but  this  decision  must  be  left 
to  the  Supervisor. 


PHYSICIANS, 


Family  Physician.  Urge  the  family  to  choose  one 
physician  and  to  retain  him.  See  that  no  one  is  giving 
or  carrying  out  orders  for  more  than  one  physician  at 
the  same  time  for  one  patient.  If  the  family  insists 
upon  changing  the  physician,  see  that  all  medicine  pre- 
scribed by  the  first  physician  is  thrown  out  before 
other  medicine  is  taken.  District  families  are  notori- 
ously impatient  and  sometimes  unwilling  to  give  a 
physician  time  to  improve  a patient's  condition.  Do 
not  make  it  too  easy  nor  too  inexpensive  for  such  fami- 
lies to  call  new  physicians  every  other  day. 

Private.  Refer  ambulant  cases  able  to  pay  for  atten- 
tion to  local  physician's  office,  or  advise  the  family  to 
call  in  the  physician  of  its  choice.  If  the  family  does 
not  know  any  physician,  has  no  preference  and  there  is 
time,  advise  it  to  call  up  the  office  of  the  Chicago 
Medical  Society  and  a list  of  physicians  residing  in  that 
locality  will  be  sent  it.  Or  give  the  family  several 
names  of  neighborhood  physicians  and  let  it  make  its 
own  investigation  and  select  its  own  physician.  Be 
sure  before  doing  this,  however,  that  the  family  is  tell- 
ing you  the  truth  and  is  not,  at  the  same  time,  employ- 
ing a regular  physician.  Many  patients  seem  to  think 
that  it  is  wise  to  be  on  the  safe  side  and  go  to  more  than 
one  physician  at  a time.  Responsibility  for  this  state 
of  affairs  is  laid  by  them  on  the  shoulders  of  the  visiting 
nurse,  to  whom  they  appeal  for  advice. 

Standing  Orders.  If  no  orders  have  been  left  for  the 
visiting  nurse  or  no  physician  is  in  attendance,  the 
printed  standing  orders  may  be  followed,  but  the  family 
should  be  instructed  to  summon  a physician  before  the 
nurse’s  next  visit.  Patients  in  need  of  medical  super- 
vision other  than  cases  for  convalescent  homes,  vacation 
camps  or  dispensary  care,  may  not  be  treated  after  the 
first  twenty-four  hours. 


16  Visiting  Nurse  Manual 

STANDING  ORDERS  FOR  THE  VISITING  NURSE 
ASSOCIATION  OF  CHICAGO. 


Corrected  and  Approved  by  the  Chicago  Medical  Society. 


FOR  ALL  NEW  PATIENTS.  Cleansing  Bath,  P.  R.  N. 
Instruction  in  hygiene  of  the  sick-room,  with  spe- 
cial emphasis  on  good  ventilation,  cleanliness,  and 
diet  suited  to  the  patient’s  conditions  and  needs. 

FOR  PATIENT  WITH  FEVER,  UNDIAGNOSED. 
Liquid  Diet. 

Low  S.  S.  Enema,  P.  R.  N.  when  no  abdominal  pain 
or  tenderness  is  present. 

Sponge  for  R.  T.  102.5. 

FOR  INFANTS  AND  CHILDREN,  WITH  FEVER, 
UNDIAGNOSED. 

Normal  Salt  Flushing,  P.  R.  N. 

Diet — Boiled  water  for  twenty-four  hours. 

BURNS. 

Remove  clothing  if  not  attached  to  skin.  If  ad- 
herent, cut  away  as  much  as  possible  and  apply 
normal  salt  or  boric  solution  dressings. 

If  severe  burn,  get  into  hospital  as  quickly  as 
possible. 

COLDS.  Low  S.  S.  Enema.  Liquid  Diet. 

For  adults,  plenty  of  hot  water  to  drink. 

INFANTILE  DIARRHEA  AND  INFANTILE  CON- 
VULSIONS. 

Normal  salt  flushing,  P.  R.  N. 

No  food. 

Boiled  water  for  twenty-four  hours. 

FOR  INFECTIOUS  DISEASES.  Isolate. 

Boric  solution  for  eyes  and  nostrils,  P.  R.  N. 
Vaseline  or  cold  cream  for  lips  and  nose,  P.  R.  N. 
Oil  Rub,  P.  R.  N.,  for  all  desquamating  cases. 
Liquid  diet. 

Sponge  for  R.  T.  102.5. 


Physicians 


17 


FOR  DISCHARGING  EARS. 

Cleanse  the  outer  ear  with  moist  boric  solution 
swabs.  Dry  thoroughly. 

Do  Not  Irrigate. 

Emphasize  need  of  prompt  medical  attention. 

FOR  DRESSINGS,  MINOR.  (Cuts,  Bruises,  Infected 
Fingers,  Scratches.) 

Apply  hot  boric  packs.  Advise  medical  attention. 

FOR  PLEURISY.  Apply  tight  binder  to  chest. 
PNEUMONIA.  Cold  air  treatment  if  possible. 

Low  S.  S.  Enema,  P.  R.  N. 

Sponge  for  R.  T.  102.5. 

Liquid  diet. 

SORE  THROAT.  Liquid  diet. 

Isolate,  if  possible,  until  physician  sees  case. 

TYPHOID  FEVER.  Low  S.  S.  Enema,  P.  R.  N. 

Sponge  for  R.  T.  102.5. 

Milk  diet. 

Emphasize  need  of  screens,  fresh  air,  cold  drinking 
water  (boiled,  if  possible),  disinfection  of  stools. 
ULCERS,  Chronic. 

Cleanse  with  lysol  or  boric  solution. 

Apply  hot  boric  dressings  and  firm  bandage. 

OBSTETRICAL  CASES. 

For  the  Mother. 

Cleansing  bath. 

Local  cleasing  with  lysol  solution. 

Abdominal  binder. 

Change  pads. 

Breast  binder,  P.  R.  N. 

Low  S.  S.  Enema,  P.  R.  N. 

For  the  Baby. 

Alcohol  dressing  to  cord. 

Oil  and  bathe. 

Soap  suppository,  P.  R.  N. 

N.  B. — Any  or  all  of  these  orders  may  be  canceled  or 
substituted  for  at  any  time  by  the  physician  on  the  case 
who  prefers  to  leave  specific  written  orders  in  each 
family.  These  standing  orders  are  merely  suggested 
as  aids  to  both  the  physicians  and  nurses,  and  will  be 


18 


Visiting  Nurse  Manual 


carried  out  when  no  other  orders  are  left.  Nurses  will 
communicate  with  the  physicians  by  telephone  whenever 
possible,  but  the  above  orders  are  intended  to  serve  for 
the  interim. 

A request  for  diagnosis  and  instructions  may  be 
written  on  Visiting  Nurse  Association  paper,  signed  and 
left  for  the  physician.  A direct  communication  is  more 
satisfactory. 

It  would  be  unwise  to  leave  certain  diagnosis  in 
writing  in  patient’s  home  and  equally  bad  to  give 
others  over  the  telephone,  therefore  do  not  ask  this  if 
you  have  reason  to  believe  that  the  physician  will  refuse 
a diagnosis.  Try  to  see  him  in  his  office  and  ask  for  the 
diagnosis.  Explain  that  we  have  three  reasons  for 
desiring  careful  diagnosis: 

1.  To  enable  us  to  give  as  much  and  as  careful 
nursing  as  is  indicated. 

2.  To  protect  the  nurses  from  the  danger  of  infec- 
tion to  themselves  and  others. 

3.  To  enable  us  to  show,  by  carefully  kept  sta- 
tistics, the  kind  of  cases  under  our  care  and  the 
approximate  amount  of  nursing  service  required  by 
the  different  types  of  case. 

Never  give  any  patient  a written  statement  that  you 
are  unwilling  to  show  him  or  his  family,  for  even  a 
sealed  envelope  may  be  inspected  and  opened  as  soon 
as  your  call  is  over. 

Never  carry  a seriously  ill  patient  several  days  with- 
out telephoning  the  physician  or  consulting  with  your 
Supervisor.  Grave  responsibility  should  always  be 
shared.  Except  in  serious  emergencies,  when  there  is 
no  time  to  telephone  a physician  or  the  Main  Office,  do 
not  initiate  any  treatment  other  than  that  permitted  in 
the  standing  orders.  These  standing  orders  are  for 
temporary  use  only,  to  save  the  patient  unnecessary 
suffering  and  discomfort  and  the  nurse’s  time. 

The  co-operation  of  physicians  and  family  should  be 
sought  in  persuading  all  seriously  ill  patients  in  con- 
gested homes  to  go  to  hospitals. 

When  complications  arise,  all  differences  of  opinion 
should  be  referred  to  the  Supervisor. 


NURSING  SERVICE. 

NURSING  CARE. 

Good  Nursing  Care  Includes 

1.  General  care  of  the  patient. 

2.  Bed-making. 

3.  Care  of  sick  room. 

4.  Instruction  of  family. 

1.  General  Care  of  Patient. 

Temperature,  pulse  and  respiration;  full  or  partial 
bath,  care  of  hair,  teeth,  nails,  etc. 

After  the  first  call,  instruct  the  family  to  have  hot 
water,  clean  linen,  newspapers,  basin  and  soap  ready 
for  your  next  call. 

T.  P.  R.  Always  use  watch  to  count  pulse  and 
respiration  and  length  of  time  thermometer  is  held  in 
mouth  or  rectum.  Record  before  leaving  house. 

Full  bath  includes  bathing  of  entire  body,  care  of 
teeth,  hair  and  nails.  Partial  bath  includes  bathing 
face  and  hands,  rubbing  back  with  alcohol,  care  of 
teeth,  hair  and  nails.  In  giving  a bath  use  plenty  of 
hot  water  and  soap.  Pay  particular  attention  to 
pressure  spots,  back  and  axillae.  In  acute  cases  give 
bath  or  alcohol  sponge  daily.  In  dirty  cases  examine 
carefully  for  head  and  body  vermin. 

Never  permit  unnecessary  exposure.  Respect  mod- 
esty where  it  exists.  Teach  it  by  example  where  it  is 
unknown. 

Hair  should  be  combed  daily.  Protect  the  pillow  with 
a towel;  use  alcohol  for  snarls.  If  this  is  left  to  the 
family,  have  someone  watch,  the  process  on  the  first  day. 
Teach  her  how  to  avoid  pulling,  prevention  of  snarls 
and  to  braid  in  two  braids.  Use  patient’s  comb,  if  pos- 
sible. Sterilize  the  metal  comb  before  returning  to  bag. 
Never  cut  a child’s  or  a delirious  patient’s  hair  without 
permission  from  a responsible  relative. 


20 


Visiting  Nurse  Manual 


Teeth.  If  the  patient  has  no  toothbrush,  make  cotton 
applicator  and  use  boric  solution  or  weak  alcohol  solu- 
tion as  a mouth  wash,  daily.  Advise  family  to  pur- 
chase alkaline  mouth  wash  and  toothbrush.  (Ask  Super- 
visor for  these  if  the  family  is  too  poor.)  Insist  upon 
the  frequent  use  of  a mouth  wash  and  of  the  tooth 
brush  if  the  patient  is  strong  enough  to  do  this.  Teach 
the  care  of  the  teeth  in  season  and  out  of  season,  and 
make  the  family  see  its  importance. 

Bed-Sores.  (Ref.  Maxwell  & Pope,  pp.  71-73.)  Bed- 
sores require  daily  care.  The  physician  should  be  noti- 
fied of  their  first  appearance.  Thorough  rubbing  with 
alcohol  and  powder,  and  removal  of  pressure  may  pre- 
vent their  development.  If  called  to  treat  bad,  slough- 
ing bed-sores  and  told  by  the  physician  to  give  the  usual 
treatment,  apply  hot  boric  packs  until  the  wound  and 
surrounding  area  are  in  better  condition,  then  use  zinc 
ointment  mixed  with  balsam  of  Peru  or  with  castor  oil. 
Remember  that  balsam  of  Peru  stains  bedding  indelibly. 
Caution  family  and  teach  how  to  protect  sheets  and 
night  dress.  For  reddened  areas,  a plaster  made  of  old 
linen  spread  thickly  with  zinc  oxide  ointment  and  ap- 
plied to  the  affected  spot  may  be  all  that  is  necessary. 
If  the  skin  bruises  easily,  teach  the  family  to  turn  the 
patient  at  regular  intervals,  at  least  every  two  hours, 
in  order  that  pressure  on  the  exposed  surface  may  be 
frequently  relieved.  Demonstrate  gentle  massage  (with 
alcohol  preferably)  of  pressure  area  whenever  patient 
is  turned.  Explain  its  action  and  the  effect  desired. 

2.  Bed-Making  should  be  as  complete  as  possible. 
Clean  sheets,  even  washed  and  rough  dried  daily,  are 
desirable.  By  using  two  sets  one  may  be  aired  even  if 
not  laundered.  Teach  family  the  comfort  and  advisa- 
bility of  having  fresh  night  dresses,  pillow  cases  and 
sheets  each  morning. 

Mattresses  may  be  protected  by  newspapers,  oil  cloth 
or  rubber  sheeting.  For  children  and  chronic  cases  a 
draw  sheet,  also,  is  advisable.  In  making  the  bed, 
remove  spread  and  blankets  and  make  from  the  mat- 
tress up.  Don’t  forget  to  shake  and  turn  pillows.  Soiled 
linen  should  be  folded  and,  if  no  other  receptacle  is 


Nursing  Care 


21 


provided,  rolled  in  newspapers.  It  should  never  be 
thrown  on  floor  nor  handled  so  carelessly  that  it  touches 
the  nurse’s  uniform. 

3.  Care  of  Sick  Room. 

(a)  Choice  of  room  is  necessarily  restricted.  Be 
guided  by  light,  ventilation  and  location.  Do  not  use 
kitchen  if  possible  to  use  any  other  room.  Parlor  is 
frequently  best  of  all.  Avoid  dark  room  or  stuffy 
alcove. 

(b)  Removal  of  Superfluous  Furniture.  Rugs,  carpet, 
upholstery,  chairs,  etc.,  should,  if  possible,  be  put  in 
adjoining  rooms.  Clean  towels  or  papers  may  be  used 
to  cover  tables.  If  the  case  is  contagious,  protect 
heavy  furniture  and  bookcases  with  cotton  sheets  or 
covers  of  some  washable  material. 

(c)  Teach  some  member  of  the  family  the  importance 
and  method  of  damp  sweeping  and  moist  dusting. 

(d)  Position  of  Patient’s  Furniture.  Move  bed  so 
that  air  may  circulate  thoroughly  about  it.  Raise  low 
bed  on  blocks.  Arrange  bedside  table  for  use  of  patient 
only.  Discourage  leaving  any  food,  candy  or  fruit  on 
the  table  after  the  patient’s  appetite  is  satisfied. 

(e)  Ventilation.  When  teaching  ventilation,  teach  a 
form  that  will  freshen  the  air  of  the  room,  but  not  one 
that  will  chill  the  whole  house  and  be  disregarded  as 
soon  as  the  visiting  nurse  leaves. 

(Window-board,  window  open  top  and  bottom,  clothes- 
frame  screen,  foot  or  head  of  bed  screened  with  shawl 
or  sheet,  large  chair  between  bed  and  window,  open 
umbrella  over  patient,  two  thicknesses  of  cheesecloth 
tacked  in  window,  etc.) 

Recommend  deodorizer  only  when  natural  ventilation 
is  not  sufficient  to  remove  odors. 

Never  go  out  of  the  sick  room  without  leaving  some 
visible  evidences  of  the  time  spent  there.  Work  swiftly 
but  not  nervously  nor  hurriedly.  Let  the  patient  see 
that  you  have  all  the  time  her  welfare  requires,  but 
teach  the  family  that  your  time  is  valuable  and  their 
help  necessary.  Instruct  some  one  member  in  the  care 


22 


Visiting  Nurse  Manual 


of  the  sick  room,  and  by  encouragement  and  occasional 
assistance,  see  that  the  room  is  kept  bright  and  clean. 
No  call  is  well  made  if  this  instruction  is  neglected. 

4.  Instruction  of  Family.  Never  leave  written  nor 
printed  orders  unless  you  are  sure  that  they  are  under- 
stood. Select  one  responsible  individual  in  the  family, 
parent  or  older  child,  and  teach  very  slowly  and  care- 
fully. Repeat  this  instruction  at  every  visit.  Remem- 
ber that  you  are  trying  to  impart  in  a few  moments 
facts  that  you  spent  months  in  acquiring,  and  do  not 
expect  too  much  from  the  average  household.  Don't 
attempt  too  much  in  one  visit,  particularly  the  first. 
For  instance,  in  typhoid,  emphasize  care  of  hands,  of 
excreta  and  reason  for  liquid  diet.  In  tuberculosis,  em- 
phasize care  of  sputum,  dishes  and  sleeping  room.  Don't 
cover  twelve  points  in  one  call,  for  the  patient  will  be 
too  confused  to  remember  anything  correctly.  Have 
your  points  clearly  defined  and  outlined  in  your  own 
mind  and  teach  the  patient  what  he  seems  to  compre- 
hend in  one  visit. 

Don't  be  misled  by  his  apparent  grasp  of  a difficult 
subject.  Patients  like  to  please  and  often  pretend  that 
they  understand  perfectly  when  in  reality  they  have  not 
been  able  to  grasp  half  of  what  has  been  said  to  them. 
When  teaching  through  an  interpreter,  demonstrate 
even  little  points  i.  e.,  open  a window,  prepare  a gargle, 
dust  something  with  a damp  cloth,  make  strong  soap- 
suds for  dishes,  etc.).  In  cases  of  infectious  diseases, 
before  warning  and  instructing  the  family  in  special 
precautions,  communicate  with  the  physician  in  attend- 
ance and  ask  if  he  would  prefer  to  do  this  himself. 

5.  Amount  to  Be  Left  to  Family,  and  Amount  to 
Be  Done  by  Nurse. 

(a)  Nothing  should  be  left  to  an  already  overworked 
woman. 

(b)  If  the  patient  is  a man  who  prefers  to  have  his 
wife  or  mother  care  for  him,  be  sure  that  she  has  been 
very  carefully  instructed  and  understands  clearly  what 
to  do. 

(c)  When  a treatment  is  left  to  the  family,  be  sure 


Fees  and  Gifts 


23 


to  teach  the  quickest,  easiest  and  gentlest  method  of 
removing  and  destroying  old  dressings,  caring  for  soiled 
linen,  removing  odors  and  protecting  hands  and  furni- 
ture. 

(d)  Nothing  should  be  left  to  the  family  that  is  prop- 
erly the  nurse’s  duty,  but  every  patient,  particularly  if 
bed-ridden,  will  require  some,  if  not  a great  deal  of 
attention,  between  visits.  In  most  families  your  advice 
and  help  will  be  gratefully  received  and  your  instruction 
followed,  if  it  has  been  understood.  Explain  and  em- 
phasize 

(1)  Value  of  fresh  air; 

(2)  Thorough  and  frequent  washing  of  hands  (pa- 
tient’s as  well  as  attendant’s); 

(3)  Need  of  sleep  (of  naps  for  convalescents  and 
little  children); 

(4)  Preparation  of  clean  and  simple  food. 

Respect  racial  and  local  traditions  wherever  you  can. 

When  these  must  be  disregarded,  let  the  family  see  that 
this  is  for  the  patient’s  welfare,  not  for  their  or  your 
convenience.  Teach  that  we  are  all  Americans  and  that 
American  customs  are  the  best  to  adopt  in  a new 
country. 


FEES  AND  GIFTS 

Nursing  Service  is  furnished  free  to  those  unable  to 
pay  for  it;  to  industrial  policy  holders  of  the  Metro- 
politan Life  Insurance  Company;  to  members  of  the 
Royal  Arcanum  Hospital  Bed  Fund  Association,  and  to 
employes  of  different  firms  in  Chicago  whose  employers 
ask  the  Association  to  give  these  services  at  the  firm’s 
expense.  From  all  other  patients  remuneration  to  the 
extent  of  from  10c  to  50c  per  visit  is  expected.  These 
patients  should  be  told  that  the  money  thus  received 
enables  the  Association  to  extend  its  work  among  their 
less  fortunate  neighbors.  If  patients  cannot  pay  the 
exact  cost  of  service  or  supplies  furnished,  teach  them 
that  10c  pays  the  nurse’s  carfare  and  enables  her  to  go 
more  quickly  to  another  case.  Fees  thus  received  should 
be  entered  on  a receipt  card,  which  is  left  with  the 


24 


Visiting  Nurse  Manual 


patient,  on  the  patient’s  record  at  the  substation,  and 
on  the  daily  report.  All  money  received  from  patients 
for  supplies,  services,  or  gifts  to  the  Association  should 
be  given  the  Supervisor  daily.  If  the  patient  gives 
money  as  a gift  to  the  Association,  acknowledgment  is 
always  sent  through  the  Main  Office. 

Patients  able  to  pay  $1.00  a visit  should  be  referred 
to  an  hourly  nurse.  Arrangements  for  this  should  be 
made  by  the  Visiting  Nurse  Association,  in  order  that 
there  may  be  no  break  in  the  nursing  care.  Hourly 
nurses  may  be  secured  from  nearly  all  nurses’  regis- 
tries. If,  however,  such  care  cannot  be  obtained,  the 
patient  should  be  carried  by  the  visiting  nurse. 

Nurses  should  receive  no  gifts  from  patients  for 
their  services,  but  may  accept  such  contributions  as 
patients  may  wish  to  make  to  the  Association.  Any 
gifts  (money,  clothing,  etc.)  made  to  individual  nurses 
for  special  patients  should  be  reported  for  acknowledg- 
ment to  the  Main  Office. 

RELIEF  AND  CO-OPERATION 

The  Association  is  strictly  non-sectarian  and  non- 
political. No  money  or  other  relief  may  be  given  pa- 
tients except  in  emergencies  when  patients  are  found 
suffering  for  food  and  fuel.  Every  case  thus  assisted 
should  be  reported  immediately  to  the  proper  agency  for 
further  investigation  and  relief,  and  to  the  Supervisor 
during  the  next  substation  hour.  Teach  patients  to 
value  our  care  for  its  own  worth.  Our  best  influence  in 
our  districts  depends  largely  upon  personal  service  to 
our  patients,  who  should  be  taught  not  to  expect  mate- 
rial relief  from  the  Association.  Public  health  nurses 
who  must  assume  this  responsibility  should  study  to 
give  relief  wisely. 

Medical  Relief.  Baby  outfits,  surgical  apparatus, 
wheel  chairs,  crutches,  braces,  binders,  etc.,  are  some- 
times supplied  by  the  Association  to  patients  carried 
in  its  districts. 

Special  Nurses.  When  no  other  care  can  be  arranged, 
the  Association  sometimes  assumes  the  expense  of  a 


Relief  and  Co-operation  25 

special  nurse  for  an  acutely  ill  patient.  The  following 
rules  should  be  observed: 

1.  A special  nurse  should  never  be  put  on  any  case 
without  consultation  with  the  Supervisor,  or  the  Main 
Office  if  the  Supervisor  cannot  be  reached. 

2.  Patients  requiring  special  nurses  must  first  be 
seen  by  a district  nurse  and  should  be  seen  by  the  Super- 
visor within  twenty-four  hours. 

3.  The  nurse  in  the  district  should  visit  a “special- 
nurse”  patient  at  least  every  second  day  and  give  a 
report  of  each  visit  to  the  Supervisor. 

4.  No  special  nurse  may  be  left  on  longer  than  one 
week,  unless  the  patient  has  been  seen  a second  time 
by  the  Supervisor  and  there  is  some  excellent  reason 
why  the  patient  cannot  be  moved  to  the  hospital  or  left 
entirely  in  our  care. 

5.  Special  nurses  may  not  be  put  on  terminal  chronic 
cases. 

6.  A special  nurse  should  never  be  requested  when 
the  patient  can  be  removed  to  an  institution  or  cared 
for  by  some  member  of  the  family,  with  a twice-daily 
visit  from  the  district  nurse.  On  the  other  hand,  every 
nurse  should  be  very  careful  to  see  that  the  family  is 
not  breaking  down  under  the  strain  of  the  care  of  an 
acutely  ill  person. 

To  put  a special  nurse  in  a household  requires  the 
exercise  of  good  judgment  on  the  part  of  a district 
nurse,  and  to  remove  her  sometimes  involves  more. 

Reports  to  Other  Agencies.  Before  reporting,  verb- 
ally or  in  writing,  any  patient  other  than  an  emergency 
case,  to  a co-operating  agency,  consult  your  Supervisor 
in  regard  to  it.  Never  take  time  to  put  in  writing  what 
can  be  telephoned  or  personally  reported.  When  making 
these  reports,  emphasize  medical  aspect  of  case  and 
give  your  reasons  for  believing  that  aid  (material  or 
otherwise)  is  needed. 

The  other  society  probably  has  or  will  obtain  for 
itself  social  data.  For  example,  don’t  ask  that  special 
diet  and  fuel  be  given  immediately  to  Mrs.  White,  a 


26 


Visiting  Nurse  Manual 


widow  with  seven  children,  living  in  a four-room,  $8.00- 
a-month  basement  flat,  income  irregularly  $3.50  a week 
from  earnings  of  a fifteen-year-old  girl. 

State  that  the  third  child  has  pneumonia,  is  in  a 
critical  condition,  able  to  take  very  little  nourishment 
of  any  kind,  and  cannot  be  moved  to  a hospital;  that 
mother  has  diabetes,  which  also  requires  a special  diet; 
then  ask  for  specific  kinds  and  amounts  of  food  for  both 
patients  (1  quart  of  milk  daily,  2 dozen  eggs  weekly,  1 
pound  beef  daily  for  beef-juice,  5 pounds  of  diabetic 
flour  bi-weekly,  etc.). 

Later  call  at  office  and  see  if  arrangements  can  be 
made  to  keep  mother  supplied  with  diet  required  in 
diabetes. 

Emphasize  urgency  in  acute  conditions  (pneumonia, 
typhoid,  nephritis,  infection,  etc.),  but  state  when  the 
investigation  can  be  made  more  slowly  (as  in  chronic 
conditions,  rheumatism,  paralysis,  tuberculosis,  etc.). 
Give  all  the  facts  you  have  if  there  is  time,  but  put 
special  emphasis  on  those  of  first  significance  to  you. 

Registration.  Before  planning  any  action  involving 
more  than  nursing  care  in  a family,  consult  the  Social 
Service  Registration  Bureau,  Randolph  7160,  to  learn 
what  other  agencies  are  interested  in  this  same  family 
and  to  see  if  your  plans  will  conflict  with  theirs.  In 
reporting  case  to  Registration,  give,  if  possible,  the 
Christian  name  of  each  parent,  as  well  as  address  and 
part  of  house.  If  no  other  agencies  have  registered  the 
case  you  are  fairly  safe  in  making  plans. 

By  knowing  personally  representatives  of  hospitals, 
schools,  settlements,  and  other  philanthropic  agencies 
in  your  district,  you  will  be  able  to  act  promptly  in 
securing  the  needed  co-operation  of  other  social  workers 
for  your  patients.  Whenever  possible,  learn  the  names  of 
these  workers  and  keep  them  in  your  dairy  or  in  some 
other  convenient  place.  Delayed  or  poor  co-operation 
is  frequently  caused  by  misunderstanding  and  lack  of 
acquaintance  between  social  workers. 

Remember  that  each  social  worker  has,  or  should 
have  had,  a special  training.  One  can  seldom  be  expert 


Relief  and  Co-operation 


27 


in  all  lines  of  social  work.  Don't  attempt  to  shoulder 
too  much  responsibility  for  your  patient's  needs.  Give 
your  very  best  service  as  a nursing  expert  and  insist 
that  other  workers  assume  their  responsibilities  for 
relief,  legal  advice,  police  supervision,  etc. 

Agencies  that  the  visiting  nurse  should  understand 
and  co-operate  with  in  her  district  work  are: 

1.  Health  Department. 

2.  Social  Service  Registration  Bureau. 

3.  District  Office  of  County  Agent. 

4.  District  Office  of  United  Charities. 

5.  United  Hebrew  Charities. 

6.  Summer  Outing  Camps. 

7.  Illinois  Society  for  Mental  Hygiene. 

8.  Hospitals  taking  free  patients. 

9.  Dispensaries,  including  tuberculosis  and  dental 

clinics,  and  Infant  Welfare  Conferences. 

10.  Police  stations  for  ambulance  and  lung  motor 

calls,  and  for  leaving  specimens  for  City 
Laboratory. 

11.  Public  baths  and  playgrounds. 

12.  Public  schools  (open  air  schools,  social  centers 

and  dental  clinics,  night  schools,  special 
classes  for  defectives,  blind,  deaf,  crippled, 
mentally  sub-normal). 

13.  Institutional  churches  and  pastors  of  churches 

doing  neighborhood  work. 

14.  Settlements  and  day  nurseries. 

15.  Local  St.  Vincent  de  Paul  conferences. 

16.  Drug  stores  carrying  Health  Department  anti- 

toxins and  throat  culture  outfits. 

17.  Foreign  local  relief  workers  (German,  Polish, 

Italian,  etc.). 

18.  Institutional  homes  (for  aged,  children,  unmar- 

ried pregnant  girls,  etc.). 

19.  Public  baths. 


28 


Visiting  Nurse  Manual 


EMERGENCIES. 

(Maxwell  & Pope,  Chap.  XI.). 

When  treating  any  emergency,  be  sure  that  it  is  a 
real  emergency  entitled  to  medical  relief,  not  a false 
alarm.  When  in  doubt,  treat  the  case  as  an  emergency, 
but  weigh  the  merits  of  each  case  as  carefully  as  pos- 
sible. When  in  uniform  never  fail  to  offer  your  serv- 
ices, if  needed,  in  any  serious  emergency,  street  car 
accident,  fire,  epileptic  seizure,  premature  labor,  etc. 

If  not  in  uniform  and  your  assistance  seems  advisable, 
offer  it,  stating  that  you  are  a visiting  nurse.  If  a 
physician  has  been  called  and  relatives  can  attend  to 
patient,  don't  waste  time  unnecessarily. 

For  street  and  any  kind  of  fatal  home  accident,  always 
summon  a policeman.  Before  summoning  a physician 
in  minor  emergencies,  be  sure  that  the  patient  is  unable 
to  go  to  the  doctor's  office.  Do  not  summon  a physician 
unnecessarily.  A policeman  is  state  witness  and  must 
be  notified. 

Street  Accidents.  Send  for  Policeman.  Send  for 
physican  if  apparently  necessary.  Apply  tourniquet, 
clean  dressing,  or  give  any  other  indicated  first  aid. 

Coroner's  Orders.  Never  have  an  unconscious  or  a 
dead  person  removed  from  site  of  accident  except  to 
sidewalk  or  out  of  dangerous  territory.  Never  take 
the  responsibility  of  removing  such  a person  to  a hos- 
pital or  undertaking  establishment  by  street  car,  motor 
or  any  other  vehicle  before  the  arrival  of  a policeman. 

If  the  person  is  killed,  you  will  doubtless  be  sum- 
moned as  a witness  before  the  Coroner's  jury.  Remem- 
ber that  frequent  discussion  of  such  cases  is  confusing 
and  may  render  your  testimony  valueless.  Don't  have 
opinions;  state  facts  when  you  are  asked. 

Coroner's  Cases,  other  than  fatal  street  accidents,  are 

1.  Sudden  deaths  without  medical  attention. 

2.  Any  undiagnosed  death. 

3.  Any  death  resulting  from  injury  (burns,  acci- 

dents, homicide,  etc.). 


Emergencies 


29 


4.  Septicemia  following  criminal  abortion. 

5.  Death  following  criminal  abortion. 

If  you  are  called  to  attend  septicemia  following  sus- 
pected abortion,  consult  your  Supervisor  before  making 
a second  call.  These  cases  should  be  reported  to  the 
Coroner's  office  by  the  attending  physician,  but  in  case 
he  neglects  to  do  this  the  nurse  shares  this  responsi- 
bility and  is  summoned  as  a witness  at  the  inquest  if 
patient  dies. 

Pulmonary  Hemorrhage — Street.  Have  patient  raised 
in  semi-recumbent  position.  Keep  crowd  quiet.  Home. 
Cold  to  chest.  Cracked  ice  to  swallow.  Keep  patient 
and  family  quiet  while  awaiting  physician.  (Unless 
death  occurs  within  a few  minutes  pulmonary  hem- 
orrhage is  rarely  fatal.) 

Patient  in  Labor.  If  head  is  on  the  perineum,  send 
someone  for  the  nearest  physician.  Scrub  up  as  welJ 
as  you  can  and  take  the  delivery  yourself.  If  pains  are 
infrequent  and  the  patient  refuses  to  be  sent  to  a 
hospital,  see  that  a relative  or  neighbor  calls  a physi- 
cian and  remains  with  the  patient.  If  possible,  call 
later  in  the  day  to  see  how  the  patient  is  progressing. 

Convulsions — Children.  Undress  and  get  into  a hot 
bath  quickly.  Adults.  Undress  and  put  to  bed.  Try  to 
ascertain  cause  in  each  case.  If  epilepsy,  separate  teeth 
and  take  usual  precautions  to  protect  unconscious 
patient  from  injury. 

Loss  of  Consciousness.  Put  patient  in  recumbent  posi- 
tion. Loosen  clothing.  If  fainting,  lower  head  and 
bathe  hands  and  face. 

Electric  Shock.  Asphyxiation  (by  drowning,  hanging, 
stove  or  illuminating  gas,  smoke,  etc.).  Get  the  patient 
into  the  fresh  air.  Start  artificial  respiration  at  once. 
Have  trustworthy  person  telephone  nearest  police  am- 
bulance station  for  lung-motor.  Have  neighbor  make 
strong  black  coffee  for  rectal  enemata.  Give  every  on- 
looker something  to  do  and  keep  them  all  away  from 
the  patient.  If  crowd  is  large,  have  men  form  cordon 
around  patient. 


30 


Visiting  Nurse  Manual 


Heat  Prostration.  Recumbent  position.  Keep  people 
quiet.  Apply  cold  to  face  and  temples.  Move  patient 
into  nearest  cool  place.  Loosen  clothing.  If  at  home, 
give  cold  sponge  with  friction  until  doctor  arrives. 

Hysterical  and  Epileptic  Seizures.  Get  history  of 
case  from  family  before  calling  physician.  If  there  is 
history  of  frequent  similar  attacks,  let  family  call  their 
own  physician  or  carry  out  the  treatment  previously 
ordered.  If  no  history  can  be  obtained  and  no  physician 
is  indicated,  have  family  or  neighbor  call  one  from  the 
neighborhood. 

Internal  Poisoning.  If  the  poison  is  known,  prepare 
and  administer  antidote  while  waiting  for  the  physician. 
Remember  that  most  cathartics  and  headache  powders 
found  in  district  homes  contain  dangerous  stimulants 
and  sedatives.  Warn  parents  carefully  and  teach  them 
how  to  stopper  and  label  all  poisonous  drugs  so  that  the 
receptacle  may  be  detected  in  the  dark  as  well  as  the 
daylight. 

The  following  is  a list  of  poisons  with  their  antidotes: 

Carbolic  Acid.  Whiskey  or  50  per  cent  alcohol; 
lime  water;  olive  oil. 

Washing  Fluid  (Alkali-Caustic  Potash).  Lemon 
juice  or  vinegar;  heat  and  stimulants;  no  emetic. 

Fly  Poison  (Arsenic).  Rough  on  Rats  (Arsenic). 
Chalk  and  water,  flour  and  water,  magnesia  and 
tincture  or  iron,  followed  by  milk;  then  an  emetic. 

Bichloride  of  Mercury.  One  egg  to  every  4 grains 
of  mercury;  emetic. 

Soothing  Syrups  (Opium).  Black  coffee,  normal 
salt  flushing;  emetic  as  soon  as  patient  can  be  suf- 
ficiently roused  to  swallow. 

Stings  and  Bites  of  Harmful  Insects.  (Bees,  Mos- 
quitoes, Bedbugs,  Flies,  etc.).  Frequent  bathing  with 
soda  bicarbonate  solution  and  light,  moist  bandaging 
with  soda,  witch  hazel,  weakened  ammonia  or  alcohol 
solution  for  twenty-four  hours  may  prevent  scratching 
and  subsequent  infection.  With  babies  and  little  chil- 
dren this  is  a very  important  item. 


Emergencies 


31 


Dog  Bites.  Send  for  policeman  and  physician.  Do 
not  let  anyone  kill  dog  if  he  can  be  restrained  until 
arrival  of  police.  Dr.  A.  Lagorio  of  the  Pasteur  Insti- 
tute, Chicago,  advises  the  following,  when  nurse  must 
give  first  aid: 

For  superficial  wound,  cauterize  with  carbolic  (95  per 
cent)  and  dress  with  boric  solution  pack.  For  deeper 
wounds,  irrigate  with  lysol  solution  (2  per  cent)  or 
peroxide  (50  per  cent);  pack  wound  with  gauze  dipped 
in  boracic  solution  (saturated),  and  apply  pack  of  equal 
strength. 

Dog  bites  should  always  be  reported  to  the  police, 
even  if  the  wound  is  several  days  old  when  nurse  first 
sees  it.  The  police  report  to  the  Health  Department 
when  this  is  necessary. 

Death.  If  death  occurs  during  the  nurse's  visit,  help 
each  family  as  occasion  indicates.  Let  the  family  send 
for  the  undertaker,  or  if  you  do  this,  see  that  the  under- 
taker understands  clearly  who  is  to  make  settlement  for 
the  funeral.  If  county  or  free  burial  is  necessary,  call 
the  County  Agent's  Office  and  report  the  death,  stating 
the  nature  of  the  case.  When  office  is  closed,  notify 
nearest  police  station. 

Whenever  any  difficulty  is  experienced  in  disposing 
of  a dead  body,  have  the  family  notify  the  nearest 
police  station.  If  foul  play  is  suspected,  notify  Cor- 
oner's Office. 

In  particularly  distressing  conditions,  see  if  a relative 
or  neighbor  can  be  persuaded  to  remain  with  the  be- 
reaved family.  When  death  is  anticipated  by  the  fam- 
ily, discuss  the  funeral  expenses  with  them,  and  try  to 
persuade  them  that  their  responsibility  in  this  regard 
is  greater  to  the  living  than  to  the  dead  and  that  a 
modest  funeral  shows  as  much  respect  to  the  dead 
member  as  one  that  uses  up  all  the  savings  and  insur- 
ance or  puts  the  family  in  debt. 

When  visiting  a terminal  case,  ask  if  the  family  de- 
sires a clergyman,  and  report  the  patient  to  the  nearest 
representative  of  the  denomination  chosen  by  the  fam- 


32 


Visiting  Nurse  Manual 


ily.  If  unexpected  death  in  acute  cases  seems  imminent, 
warn  the  family,  summon  the  nearest  physician,  and 
give  treatment  as  in  any  emergency. 

Relief  Emergency.  Fuel  or  Food.  If  you  find  case 
in  late  afternoon  or  on  Saturday,  purchase  supply  for 
over  night  or  for  a few  hours.  Call  up  the  County 
Agent  if  a county  family,  or  the  United  Charities  or 
United  Hebrew  Charities,  stating  the  need  as  you  have 
seen  it,  and  asking  for  immediate  temporary  relief  and 
a more  thorough  investigation.  Be  careful  not  to  give 
emergency  relief  in  families  already  under  the  super- 
vision of  a relief  agency.  If  you  differ  with  the  other 
agency  in  regard  to  its  treatment  of  any  family  group, 
go  and  talk  the  case  over  frankly  with  the  worker.  Do 
not  upset  her  plans  by  giving  unwise,  although  perhaps 
to  you,  clearly  indicated,  temporary  relief. 

Housing  Emergencies.  Frozen  Pipes.  Report  to  the 
Sanitary  Board  of  the  Health  Department,  with  the 
length  of  time  frozen  and  state  if  this  is  the  only  water 
supply  in  the  house. 

Water  Cut  Off.  Report  to  the  Water  Department, 
City  Hall. 

Plumbing  Out  of  Order.  Report  to  the  Sanitary 
Bureau  of  the  Health  Department,  with  the  length  of 
time  that  the  toilet  and  drains  have  been  working  badly 
or  not  at  all. 

Dark  Rooms,  Unsafe  Stairs  and  Elevators.  Report 
to  the  Building  Department,  City  Hall. 

Do  not  report  by  telephone  any  of  the  above  condi- 
tions unless  a real  emergency.  Report  all  cases  (emer- 
gency or  otherwise)  by  usual  mailing  card  sent  through 
Main  Office. 

Eviction.  Report  to  County  Agent  or  United  Chari- 
ties. Evicted  families  are  usually  old  relief  cases  and 
known  to  above  agencies.  The  process  of  eviction  takes 
at  least  fifteen  days  from  the  serving  of  the  first 
warning. 


Free  Medical  Service  33 

FREE  MEDICAL  SERVICE. 

Free  care  of  the  indigent  sick  may  be  obtained 
through : 

1.  Physicians,  county  and  private. 

2.  Hospitals,  private  and  public. 

3.  Dispensaries. 

4.  Convalescent  homes. 

5.  Infant  Welfare  Society  (children  under  2 years 
of  age.) 

6.  Municipal  Tuberculosis  Sanitarium  Dispensary 
Department. 

7.  Health  Department. 

8.  Illinois  Society  for  Mental  Hygiene. 

Physicians.  Before  trying  to  obtain  free  service 
(except  in  emergencies)  be  sure  that  the  family  has 
not  an  attending  physician,  that  no  physician  has  been 
in  attendance  and  that  the  family  is  unable  to  pay  a 
local  physician.  (To  decide  this  latter  point  the  Social 
Service  Registration  Bureau  may  be  able  to  help  you.) 
If  the  family  has  had  a physician  in  the  past,  talk  to 
him  and  give  him  the  opportunity  to  treat  the  patient 
without  a fee.  In  doubtful  cases,  ask  some  member  of 
the  family  to  call  the  County  Doctor.  If,  in  your  judg- 
ment, a free  physician  is  not  needed  and  the  family 
insists  upon  receiving  free  treatment,  let  some  member 
ask  for  it,  thus  putting  the  responsibility  where  it 
belongs.  If  a free  physician  is  in  attendance,  do  not 
send  him  unnecessary  calls  simply  because  the  family 
or  the  patient  desires  to  see  him.  Let  such  calls  come 
from  some  member  of  the  family.  Unless  you  are  sure 
the  physician  would  change  the  treatment  and  wishes 
to  be  notified,  do  not  ask  any  of  his  free  time  unneces- 
sarily. 

Local  physicians  are  often  willing  to  make  free  calls 
in  cases  of  emergency,  to  carry  patients,  to  see  our 
patients  at  their  offices  and  to  take  an  occasional  obstet- 
rical case.  Many  specialists  are  good  enough  to  see 
our  patients  at  hospitals  or  at  their  downtown  offices. 
Before  asking  too  much  time  from  a busy  man,  talk 


34 


Visiting  Nurse  Manual 


over  such  cases  with  your  Supervisor.  Patients  should 
be  taught  that  this  is  valuable  time  and  service,  not 
too  easily  obtained  and  to  be  valued  accordinly. 

County  Physicians.  To  obtain,  call  the  County  Agent, 
Monroe  2608;  say  that  you  are  a visiting  nurse;  ask  to 
have  a doctor  sent  to  the  patient,  giving  name,  address, 
part  of  the  house  and  your  district  number.  If  the 
County  Agent's  office  is  closed,  call  the  police  station 
nearest  the  patient.  Do  not  send  the  County  Doctor  or 
any  free  physician  to  a patient  able  to  go  to  a dis- 
pensary. 

Never  refer  a patient  directly  to  the  county  physician. 
Whenever  necessary,  telephone  the  county  doctor  for 
conference  in  regard  to  a patient,  but  if  calls  for  his 
services  are  given  directly  to  him  or  to  his  office,  they 
may  never  be  made,  for  by  ruling  of  the  County  Agent's 
department  requests  for  free  medical  service  must  come 
through  the  County  Agent's  main  office,  Monroe  2608. 

Free  Hospital  Service.  Except  in  emergencies,  never 
send  any  physician's  patient  to  a hospital  without  first 
consulting  him. 

Cook  County  Hospital.  To  send  patient  to  Cook 
County  Hospital,  call  Health  Department,  Main  447, 
ambulance  department,  give  diagnosis  and  ask  to  have 
the  patient  removed.  See  that  the  doctor  has  previously 
called  and  left  an  order  for  the  County  Hospital. 

Refer  all  cases  of  suspected  contagion  to  the  Health 
Department.  Before  trying  to  send  contagious  cases  to 
Cook  County  Hospital,  telephone  and  ask  if  there  is  a 
vacant  bed. 

Oak  Forest  Infirmary.  All  cases  for  Oak  Forest 
Infirmary  (whether  general  or  tuberculous)  must  be 
cleared  through  the  County  Hospital.  All  applications 
for  admission  should  be  made  through  the  County 
Agent's  office. 

Isolation  Hospital.  To  send  a case  of  diphtheria  to 
the  City  Isolation  Hospital  or  to  Durand  Hospital,  call 
up  the  Health  Department,  ask  for  a vacant  bed  and 
ambulance  service,  giving  name,  address  and  facts. 


Free  Medical  Service 


35 


Private  Hospitals.  First  ascertain  if  there  is  a 
vacancy.  If  the  patient  is  able  to  walk  or  a child  that 
may  be  carried,  send  with  a note  explaining  all  that 
you  know  of  the  case  and  ask  for  a free  bed.  If  bed- 
ridden, call  Main  447,  Local  38,  and  ask  if  the  police 
ambulance  is  available.  This  is  a city  ambulance  and 
is  obtainable  for  tree  patients  to  private  hospitals  only 
when  the  distance  between  the  patient's  home  and  the 
private  hospital  is  less  than  the  distance  between  the 
patient's  home  and  the  County  Hospital.  Should  you 
learn  alter  a patient  has  been  sent  out  to  a free  bed 
in  a private  hospital  that  he  is  able  to  pay  and  not  enti- 
tled to  a free  bed,  telephone  and  explain  your  mistake 
to  the  hospital.  If  patient  is  able  to  make  a partial 
payment  ($5.00  rather  than  $8.00  weekly),  explain  this 
to  hospital  where  obtaining  a bed. 

Do  not  try  to  send  patients  suffering  from  venereal 
or  contagious  diseases,  tuberculosis  or  alcoholism,  or 
any  typically  County  Hospital  case,  to  private  insti- 
tutions. 

Municipal  Tuberculosis  Sanitarium  Dispensary  De- 
partment maintains  clinics  for  the  treatment  of  tuber- 
culous patients  in  various  parts  of  the  city.  Transfer 
all  positive  cases  of  tuberculosis  and  all  suspected 
patients  through  the  Main  Office.  (This  precaution  is 
taken  in  order  that  no  patient  may  be  lost  between  the 
two  societies.)  Do  not  carry  any  but  terminal  and 
surgical  tuberculous  patients. 

Advanced  cases  may  be  sent  to  Cook  County  Hospital, 
to  the  Home  for  Incurables  (Otto  Young  Pavilion.) 
Hopeful  sanitarium  cases  may  be  sent  to  Edward  Sani- 
tarium, Naperville,  111.,  Winfield  Sanitarium  or  to  Oak 
Forest  Infirmary. 

Edward  Sanitarium.  Visiting  Nurse  Association  has 
the  use  of  ten  beds.  Only  incipient  cases  are  received. 
There  is  always  a long  waiting  list  for  these  beds,  and 
patients  who  will  most  respond  to  careful  sanitarium 
treatment  and  whose  home  conditions  will  enable  them 
to  carry  on  this  treatment  after  their  discharge  should 
be  selected.  Dr.  Theodore  B.  Sachs  is  medical  examiner 


36 


Visiting  Nurse  Manual 


for  Naperville,  and  before  seeing  any  patient  for  one 
of  our  free  beds  he  desires  a record  of  the  afternoon 
temperature  for  three  days,  sputum  analysis,  a history 
of  the  case  and  the  reason  for  its  being  sent  to  him. 
(It  is  advisable  to  have  candidates  for  these  beds  sent 
through  the  Municipal  Tuberculosis  Dispensary.) 

Winfield  Sanitarium.  All  free  candidates  should  be 
referred  to  the  tuberculosis  clinic  of  the  Jewish  Aid 
Dispensary. 

Home  for  Incurables  is  a private  institution  taking 
only  positively  incurable  cases.  The  tuberculous  oa- 
tients  are  segregated  in  the  Otto  Young  Pavilion.  Ex- 
plain to  the  patient  that  a physician  from  the  home  will 
come  out  to  examine  him.  Application  should  be  made 
through  the  Main  Office  in  writing. 

The  following  information  is  desired: 

1.  Name. 

2.  Address. 

3.  Diagnosis. 

4.  Urgency  of  case. 

5.  Name  and  address  of  nearest  relative  or  friend. 

6.  Religious  preference. 

7.  Social  and  economic  condition. 

8.  Anticipated  insurance. 

Dispensaries.  Send  free  ambulatory  patients  to  the 
nearest  reliable  dispensary.  See  that  the  correct  day 
and  hour  is  obtained  for  each  patient.  Send  a note 
written  on  one  of  our  small  letterheads  to  the  physician, 
telling  him  as  much  as  is  wise  bearing  on  the  situation. 
State  that  the  patient  cannot  pay  and  ask  him  to  return 
instructions  and  diagnosis  if  possible. 

(Remember  that  patient  will  probably  read  both 
notes.)  It  is  well  to  enclose  this  in  a sealed  envelope 
on  which  should  be  plainly  written  the  address  of  the 
dispensary  and  the  car  lines  and  transfer  points.  The 
envelope  will  probably  be  shown  to  several  policemen, 
conductors  and  pedestrians  before  the  patients  arrive 
at  their  destination. 


Free  Medical  Service  37 

Instruct  the  patient  how  to  obtain  a dispensary  card 
and  how  to  care  for  it. 

If  the  patient  is  a child  and  the  nurse  takes  him, 
obtain  permission  from  the  parent  or  guardian  and  get 
written  permission  to  have  any  treatment  given  (i  e.,  tu- 
berculin test,  tooth  extracted,  abscess  opened,  etc.) 
When  working  with  difficult  patients  never  put  in  writ- 
ing diagnosis  of  specific  or  other  infectious  trouble. 
Never  repeat  carelessly  advice  and  warning  of  the  phy- 
sician. Regard  these  as  confidential  and  report  only  to 
people  interested  in  doing  the  best  for  that  unfortunate 
person’s  welfare. 

Convalescent  Homes.  Grove  House  for  Convales- 
cents at  Evanston.  The  Visiting  Nurse  Association 
has  the  use  of  ten  free  beds  to  which  it  may  send 
women  and  children  who  are  able  to  go  from  their  bed- 
rooms to  the  dining  room  and  to  take  care  of  them- 
selves generally.  Tuberculous,  infectious  and  mental 
cases  are  not  admitted.  All  applicants  for  admission 
must  be  examined  by  a physician  selected  by  Grove 
House.  To  secure  a vacancy  for  a patient,  report  name 
and  address,  present  physical  condition  and  previous 
diagnosis  to  the  Registrar  at  the  Main  Office. 

Convalescing  women  and  children  may  also  be  sent 
to  the  Chicago  Home  for  Convalescent  Women  and 
Children,  1516  West  Adams  street.  Application  for  this 
should  be  made  directly  through  the  superintendent  of 
the  home. 

Disposition  of  Children.  Never  send  a mother  to  a 
hospital  or  home  without  being  sure  that  minor  children 
are  being  cared  for.  We  may  ask  relatives,  trustworthy 
neighbors  who  are  friends  of  the  mother,  or  institutions 
(the  Home  for  the  Friendless  or  St.  Joseph’s  Home  for 
the  Friendless)  to  care  for  children  during  the  mother’s 
absence.  Make  application  for  the  latter  through  St. 
Vincent  de  Paul  Society.  Delicate  children  may  also 
be  boarded  in  private  families  through  the  Illinois  Home 
and  Aid  Society  (Protestant),  St.  Vincent  de  Paul 
Society  (Catholic)  or  the  Jewish  Home  Finding  Society. 

Children  of  school  age,  excluded  from  regular  school 


38 


Visiting  Nurse  Manual 


work  because  of  physical  or  mental  defects,  may  be 
admitted  to  special  rooms  for  crippled,  sub-normal,  blind 
or  deaf  children  if  application  is  made  to  the  Child 
Study  Department  of  the  Board  of  Education. 

Feeble-minded  children  may  be  sent  to  the  State 
School  at  Lincoln  through  the  County  Agent's  office. 

Summer  Outings  may  be  arranged  through  the  United 
Charities,  various  settlements,  churches  and  other  or- 
ganizations. Every  child  sent  should  be  examined  for 
pediculosis  and  communicable  disease.  If  there  has 
been  a specific  history  of  infection,  vaginal  smears 
should  be  taken. 

Sick  children  under  14  years  of  age  may  be  sent  to 

1.  Children's  Memorial  Hospital. 

2.  The  Home  for  Destitute  and  Crippled  Children. 

3.  Children's  wards  of  various  large  hospitals. 

No  child  suffering  from  contagious  disease  or  living 
in  a temporarily  quarantined  house  should  be  sent  to 
any  general  institution.  Previous  arrangements  should 
be  made  with  each  institution  before  a child  is  sent. 

Infant  Welfare  Society.  For  the  care  and  super- 
vision of  well  and  sick  babies.  Transfer  all  babies 
under  2 years  of  age  to  the  Infant  Welfare  Society 
if  living  within  the  I.  W.  S.  territory. 

Health  Department.  Report  all  cases  of  suspected 
contagion  immediately  to  the  Health  Department.  Re- 
port to  the  School  Nurses  of  the  Health  Department 
such  school  children  as  are  in  need  of  school  or  dispens- 
ary treatment.  The  school  nurses  do  not  give  home 
nursing  care. 

Illinois  Society  for  Mental  Hygiene.  Report  to  this 
society  all  cases  of  suspected  insanity,  where  careful 
social  investigation  and  advice  are  needed.  Patients 
already  diagnosed  as  positively  deranged  should  be  sent 
to  the  Detention  Hospital  for  observation  and  disposi- 
tion. Admission  to  the  Detention  Hospital  may  only 
be  obtained  through  a warrant  issued  by  the  County 
Clerk's  office.  To  secure  this  warrant  a doctor's  written 


Maternities 


39 


and  signed  statement  to  the  effect  that  he  believes  the 
patient  to  be  of  unsound  mind  must  be  taken  to  the 
County  Clerk's  office  by  a legally  responsible  person. 

Committment  of  this  sort  is  a serious  undertaking. 
The  responsibility  should  be  placed  where  it  rightfully 
belongs,  on  the  family  of  the  patient.  If,  on  the  other 
hand,  the  family  is  trying  to  conceal  the  condition  of 
an  obviously  dangerous  patient,  the  case  may  be  re- 
ported to  the  Society  for  Mental  Hygiene  or  to  the 
police,  if  so  advised  by  the  above  society. 

Dismissed  Patients.  No  patient  of  any  age  or  sex 
in  need  of  further  care  or  change  of  scene  should  be 
dismissed  from  the  books  without  a conference  with 
the  Supervisor  or  some  interested  person.  A neglected 
convalescent  is  more  difficult  to  help  than  a very  ill 
typhoid,  and  the  necessary  diet,  outing  or  rest  is  fre- 
quently overlooked  because  less  easily  obtained  than 
hospital  care.  Fraternal  orders,  churches  and  relief 
agencies  may  all  be  asked  to  give  this  sort  of  help. 
Unless  the  need  of  special  classes  of  cases  are  fre- 
quently brought  before  the  public  provision  for  them 
will  never  be  made.  Every  case  reported  helps  to 
emphasize  this  need. 

MATERNITIES 

Waiting  Maternities.  Never  carry  a pregnant  woman 
indefinitely  without  some  medical  supervision.  If  the 
patient  refuses  to  go  to  a physician,  instruct  her  as 
carefully  as  you  can  and  tell  her  that  you  will  return 
when  you  know  that  she  has  had  medical  attention. 
If  the  patient  cannot  afford  to  engage  a physician  she 
may  be  referred  to  a lying-in  out-patient  department, 
or,  with  the  aid  of  the  Supervisor,  medical  attention 
may  be  obtained  for  her  from  some  local  doctor.  It 
is  best  to  refer  patients  to  the  nearest  lying-in  dis- 
pensary. The  free  dispensaries  and  hospitals  sending 
out  nurses  and  doctors  for  the  confinement  and  after 
care  are: 

Chicago  Lying-In  Hospital  and  Dispensary,  1336 
Newberry  avenue  and  34  West  Forty-seventh  street. 


40 


Visiting  Nurse  Manual 


Rush  Medical  Dispensary,  1744  West  Harrison  street. 

Provident  Hospital,  57  West  Thirty-sixth  street. 

Policlinic  Hospital,  221  West  Chicago  avenue. 

The  above  out-patient  departments  send  out  physi- 
cians and  medical  students.  All  of  these  institutions 
wish  to  see  the  patient  as  long  before  the  confinement 
as  possible,  and  to  keep  her  under  observation  by  means 
of  a monthly  examination.  Patients  objecting  to  this 
sort  of  supervision  should  be  taught  how  much  this  care 
means  to  them,  how  much  under  other  conditions  they 
would  be  obliged  to  pay  for  it,  and  the  importance  of 
having  only  the  best  kind  of  service  for  this  and  sub- 
sequent pregnancies. 

Women  out  of  these  territories  may  be  referred  to 
local  physicians  or  to  the  Supervisors.  When  the  home 
conditions  are  bad,  it  is  well  to  persuade  such  patients 
to  go  to  hospital  lying-in  wards  for  the  confinement 
period.  This  insures  the  patient  better  care,  rest  and 
freedom  from  anxiety.  Remember  that  every  patient 
confined  at  home  manages  her  household  from  her 
bedroom  and  gets  very  little  rest. 

Explain  that  we  do  not  come  for  delivery,  but  as 
soon  as  possible  afterwards. 

Be  sure  that  the  patient  has  a visiting  nurse  card  and 
knows  how  to  reach  us. 

If  the  case  comes  to  you  as  a waiting  maternity,  try 
to  make  the  mother  feel  that  she  should  plan  to  save 
for  the  following  supplies:  Baby  clothes,  clean  sheets, 
towels,  night  gowns,  one  pound  of  absorbent  cotton, 
five-yard  box  of  gauze,  one  pint  of  alcohol.  She  should 
also  buy  or  borrow  a bed-pan. 

Tell  the  patient  that  we  will  charge  a small  fee  for 
our  nursing  care.  The  average  woman  has  eight  months 
in  which  to  make  these  preparations.  For  her  own  and 
her  baby’s  sake  she  should  be  encouraged  to  plan  for 
its  advent  and  not  to  accept  nor  expect  too  much  free 
service. 

Instruct  her  carefully  in  regard  to: 

1.  Diet — amount,  variety. 

2.  Exercise  (warn  against  heavy  lifting). 


Maternities 


41 


3.  Bathing. 

4.  Sleep. 

5.  Clothing. 

6.  Observation  of  urine  and  stools. 

Make  two  or  more  pre-natal  calls  monthly  and  ques- 
tion her  in  regard  to  her  care.  Never  frighten  nor 
worry  a pregnant  woman  about  herself,  but  let  her  see 
that  you  are  interested  in  her  welfare  and  want  to  help 
her. 

Teach  her  to  report  promptly  headache,  vomiting, 
swollen  feet,  trouble  with  eyes,  or  too  much  pain. 

Unless  you  know  that  the  patient  has  given  history 
of  previous  pregnancies  to  a physician,  question  her 
regarding  them  and  be  sure  that  all  abnormalities  are 
reported. 

Pregnant  unmarried  mothers  may  be  sent  to  the 
Foundlings’  Home  (Protestant)  or  St.  Margaret’s  Home 
or  St.  Vincent’s  Infant  Asylum  (Catholic)  or  to  the 
Florence  Crittenton  Anchorage  (non-sectarian). 

Labor.  Tell  the  patient  to  send  for  a physician  when 
pain  begins  or  membrane  ruptures.  Instruct  her  to  take 
a hot  bath  and  an  enema,  to  comb  hair  in  two  braids, 
to  have  boiling  water  and  newspapers  in  readiness. 

After  Care.  T.  P.  R.  daily. 

On  first  visit  give  general  care,  external  lysol  irri- 
gation of  vulva;  change  obstetrical  pad. 

On  following  visits  give  partial  care.  Give  at  least 
two  baths  weekly. 

Never  give  douche  unless  ordered  by  physician.  If 
there  are  stitches,  cleanse  with  lysol  solution;  dry  care- 
fully; do  not  powder  unless  ordered. 

Make  pads  each  visit  and  see  that  family  keep  them 
clean. 

Roll  soiled  dressings  up  very  carefully  and  burn 
before  leaving  house  if  possible.  See  that  some  pro- 
vision is  made  for  laundry  work. 


42 


Visiting  Nurse  Manual 


Care  of  Breasts.  Cleanse  nipples  with  boric  solution 
and  explain  this  care  and  precaution  to  every  mother. 
If  milk  comes  rapidly,  apply  a comfortable  breast- 
binder  for  a few  days. 

Wet-Nurse.  If  a mother  has  more  milk  than  her 
own  child  requires  and  can  go  out  as  a wet-nurse, 
report  to  any  large  obstetrical  service  (hospital  or 
private)  and  ask  if  a wet-nurse  is  needed. 

Breast  Feeding.  Insist  upon  breast  feeding  and 
watch  patient's  diet  carefully  if  milk  supply  is  insuffi- 
cient. Never  help  any  patient  to  dry  her  breasts  unless 
physician  so  orders. 

Don't  ever  encourage  this  if  baby  is  living  and  can 
nurse.  Breast  feeding  is  a mother's  duty,  but  the  baby's 
father  or  its  legal  guardian  (a  relative  or  the  state) 
must  make  it  possible  for  the  mother  to  give  this  care 
to  her  child. 

A mother  on  an  insufficient  diet  is  not  able  to  nurse 
her  infant  properly.  Bottle  feeding  is  sometimes  made 
necessary  because  the  mother's  diet  is  overlooked. 
Always  make  sure  that  the  breast  milk  cannot  be  im- 
proved or  increased  before  you  help  to  put  a baby  on 
bottle  feeding. 

Inquire  daily  (and  report  to  physician  P.  R.  N.)  con- 
cerning : 

(a)  After-pains. 

(b)  Amount  and  color  of  lochia. 

(c)  Condition  of  breasts. 

(d)  Urine  and  stools  of  both  mother  and  infant. 

Midwives’  Cases.  For  obvious  reasons,  visiting  nurses 
may  not  assume  responsibility  for,  nor  give  nursing  care 
to,  midwives'  cases  unless  midwife  has  been  dismissed 
and  doctor  is  summoned.  Nevertheless,  suspected  mal- 
practice, septicemia,  or  infected  eyes,  if  discovered  dur- 
ing the  first  call  in  such  cases,  should  be  reported  to  the 
Health  Department. 

Baby.  1.  Dress  cord.  Oil  rub,  sponge  bath  and 
dress  first  day. 


Surgical  Nursing  43 

2.  Cord.  If  no  other  orders  are  left,  apply  alcohol 
dressing  daily. 

3.  Bath.  Delicate  babies,  oil  rub  in  place  of  bath 
for  first  week  or  longer.  Others — sponge  bath  and  oil 
rub  until  cord  is  off  and  stump  healed;  then  tub.  Do 
not  use  powder. 

4.  Eyes.  Wipe  lids  gently  with  cotton  wet  with 
boric  solution.  Report  all  redness  to  physician.  Report 
neglected  or  badly  inflamed,  discharging  eyes  to  Health 
Department. 

5.  Mouth.  No  treatment;  2 drams  water  after  bath. 

Baby  Outfits,  consisting  of  3 flannelette  dresses,  3 
petticoats  or  pinning  blankets,  4 binders  and  6 napkins 
may  be  taken  to  any  maternity  case  needing  them  after 
the  baby  is  born.  Outfits  taken  earlier  are  frequently 
lost  or  sold.  Never  promise  an  outfit  to  a mother 
months  before  delivery,  but  encourage  her  to  prepare 
one.  Send  her  patterns  for  this  if  necessary.  Baby 
clothes  may  be  given  only  to  visiting  nurse  patients, 
not  to  dispensary  or  midwives’  cases. 


SURGICAL  NURSING 

Dressings  require: 

Newspapers,  solutions,  dressings  (gauze,  cotton  and 
old  linen),  instruments  and  bandages. 

See  that  the  family  has  newspapers  to  protect  chairs, 
floor  and  bed  and  to  receive  soiled  dressings.  Never 
use  expensive  solutions,  bandages  and  dressings  when 
soap  and  water  and  old  linen  will  suffice.  For  bandages 
substitute  slings  or  manytailed;  for  oiled  silk  use  oiled 
paper;  for  gauze  use  old  linen;  for  absorbent  use  com- 
mon cotton.  Never  destroy  any  material  that  can  be 
used  more  than  once.  By  your  own  example  teach  each 
family  ways  and  means  of  reducing  the  cost  of  illness. 
Study  each  dressing  as  a separate  problem  and  methods 
of  devising  cheaper  dressings  will  suggest  themselves 
to  you. 


44 


Visiting  Nurse  Manual 


Preparation.  Prepare  for  dressings  by  covering  the 
table  with  newspaper.  Place  solution  basin,  scalded 
before  and  after  each  using,  dressing  towel,  bandages, 
etc.,  on  this. 

Have  second  newspaper  ready  to  receive  soiled  dress- 
ings. Never  return  to  bag  for  extra  supplies  after 
treatment  is  once  started  without  taking  antiseptic  pre- 
cautions. Make  all  preparations  for  each  dressing  be- 
fore removing  soiled  dressings.  Thoroughly  scrub  hands 
with  soap  and  water  before  and  after  care. 

Solutions.  If  irrigations  are  used,  ask  family  to  set 
aside  a pitcher  or  a wide-mouthed  bottle  for  this  special 
use.  When  cold  sterile  water  is  needed,  a supply  may 
be  prepared  and  left  for  the  following  day.  The  bottle 
or  pitcher  should  be  sterilized  daily,  filled  with  boiling 
water  and  securely  stoppered  with  a cotton  and  gauze 
pad.  A clean  paper  bag  inverted  over  the  top  of  the 
receptacle  protects  the  stopper  from  dust  and  empha- 
sizes the  importance  of  all  these  precautions  in  the 
minds  of  the  family. 

No  solution  stronger  than  boric  acid,  bicarbonate  of 
soda  or  saline  should  be  prepared  and  left  in  the  homes. 
If  frequent  irrigating  with  one  of  these  solutions  is 
ordered,  prepare  a sufficient  amount  daily  and  leave  in 
sterile  pitcher,  properly  protected.  Teach  the  mother 
how  to  warm  the  solution  by  standing  it  in  a deep  pan 
of  boiling  water  and  how  to  apply  without  wasting  solu- 
tion or  wetting  clothing  unnecessarily. 

Poisons.  If  the  physician  orders  a poisonous  solution 
used,  instruct  the  mother  to  ask  him  to  write  a pre- 
scription for  the  same,  and  have  this  taken  by  the 
family  to  a neighborhood  drug  store  to  be  filled.  Teach 
the  mother  to  prepare  the  prescribed  solution,  warning 
her  daily  of  the  danger  of  leaving  this  within  reach  of 
children  or  irresponsible  adults.  Make  as  small  a quan- 
tity of  the  solution  as  possible,  and  see  that  it  is  very 
plainly  labelled  “poison.”  When  the  case  is  terminated 
or  if  the  treatment  is  changed,  ask  the  family  to  give 
you  any  of  the  solution  that  remains  (this  refers  par- 
ticularly to  carbolic  acid,  lysol,  bichloride  of  mercury, 


Surgical  Nursing  45 

chloroform  linament,  argyrol,  atropine,  strychnia  and 
opiates). 

Under  no  circumstances  should  a visiting  nurse  leave 
any  poison  from  her  own  supplies  in  a district  home. 
If  top-dressings  from  a cancer  or  any  septic  case  must 
be  left  in  strong  lysol  solution  for  any  length  of  time, 
the  receptacle  for  this  should  be  left  in  an  absolutely 
safe  place,  or  the  solution  should  be  so  diluted  just  be- 
fore the  nurse  leaves  that  no  serious  trouble  could 
follow  its  misuse. 

Supplies  when  left  in  the  homes  for  extensive  dress- 
ings, maternity  cases,  etc.,  should  be  rolled  in  a fresh 
towel  and  kept  in  a clean  place.  The  attendant  should 
be  taught  to  wash  her  hands  carefully  before  unrolling 
the  towel.  Whenever  possible,  payment  should  be  col- 
lected for  materials  left  in  the  home.  If  family  cannot 
afford  full  price,  partial  payment  may  be  made.  (This 
refers  also  to  rubber  bandages,  stockings,  abdominal 
binders,  eye  glasses,  crutches,  braces  or  any  supplies 
procured  by  the  Visiting  Nurse  Association  for  the 
patient.) 

Instruments  should  be  boiled  before  and  after  using. 
Forceps  (a  pair  in  each  hand)  should  always  be  used  to 
remove  soiled  dressings  of  any  description.  Never 
touch  a soiled  dressing  with  an  unprotected  hand.  If 
the  wound  is  septic,  no  antiseptic  precautions  in  scrub- 
bing up  in  a district  home,  will  sufficiently  disinfect 
your  hands.  (Howell  of  Columbus,  Ohio,  believes  that 
pus  germs  remain  on  infected  hands  for  three  days 
following  infection.) 

Care  of  Soiled  Dressings.  All  soiled  dressings  to  be 
destroyed  should  be  well  wrapped  in  newspapers  and 
then  burned.  Others  should  be  put  immediately  in  cold 
water  and  placed  on  stove  for  sterilization.  All  soiled 
dressings  should  be  cared  for  promptly  by  the  visiting 
nurse  or  a thoroughly  responsible  person. 

In  apartment  houses,  see  that  the  janitor  under- 
stands the  importance  of  cremating  old  dressings  with- 
out opening  the  package  to  inspect  contents. 


46 


Visiting  Nurse  Manual 


Never  permit  a family  to  throw  dressings  or  pads  of 
any  kind  in  the  ash  barrel.  Unless  families  are  watched, 
offensive  dressings  may  be  thrown  in  the  alley  or  a 
garbage  heap. 

Patients  should  be  taught  how  to  wash  bandages  and 
slings  in  order  to  have  them  ready  for  the  nurse  on 
her  next  visit.  Patients  able  but  unwilling  to  make 
this  effort  should  be  made  to  pay  for  their  own 
dressings. 

Burns  should  be  visited  daily  or  twice  daily.  To 
avoid  unnecessary  pain  or  hemorrhage,  see  that  dress- 
ings are  well  moistened  before  removing. 

Always  bear  in  mind  the  prostration  following  such 
treatment  and  remove  and  renew  dressings  in  segments 
rather  than  by  exposing  the  entire  burned  area  at 
one  time. 

Soft  old  linen  or  cotton  cloths  are  better  than  gauze. 
Never  apply  cotton  as  a dressing  to  a burned  area. 

Never  further  tire  a patient  by  giving  a full  bath 
before  or  after  an  extensive,  exhausting  dressing.  By 
partial  bathing  daily,  the  entire  body  can  be  kept  clean 
and  comfortable. 

When  wet  dressings  are  used,  take  special  precau- 
tions to  protect  mattress  and  bedding.  When  the  pa- 
tient cannot  be  turned  he  should  be  lifted  daily  in  order 
that  the  sheets  may  be  changed  and  the  patient’s  back 
and  hips  given  care.  If  there  is  no  one  in  family  to 
lift  an  adult  patient,  see  if  neighbors  cannot  be  called 
upon  to  help. 

When  dressing  burned  hands  and  feet,  fingers  and 
toes  should  be  carefully  separated.  Never  bandage  a 
burn  that  you  can  manytail. 

In  severe  or  extensive  burns,  have  the  attendant  save 
all  urine  passed  between  the  nurse’s  visits.  This  is 
safer  than  asking  to  have  it  measured. 

Ask  the  family  to  have  some  stimulating  or  soothing 
nourishment  ready  for  the  patient  at  the  end  of  the 
treatment,  hot  coffee,  broth,  or  a cooling  drink  of  some 
sort.  This  takes  the  patient’s  mind  off  his  dressing  and 
is  always  comforting. 


Surgical  Nursing 


47 


Watch  for  deformity  and  notify  physician  promptly 
when  contraction  of  skin  or  underlying  muscles  is 
threatening. 

Ulcers.  Never  change  the  treatment  without  con- 
sulting the  attending  physician  or  dispensary.  Instruct 
the  patient  to  keep  the  limb  raised  as  much  as  possible. 
Apply  bandage  firmly  from  foot  to  knee.  The  foot  and 
limb  should  be  bathed  in  hot  lysol  solution  (1  per  cent) 
whenever  the  dressing  is  changed,  and  rubbed  with 
alcohol. 

A lysol  solution  (2  per  cent)  for  sponging  and  cleans- 
ing the  wound  should  be  prepared  in  a seperate  recep- 
tacle. 

The  wound  and  surrounding  area  should  be  thor- 
oughly cleansed  from  the  center  out.  Every  precaution 
should  be  taken  to  prevent  cross  infection.  If  physician 
is  seeing  wound  infrequently,  notify  him  whenever  ulcer 
appears  enlarged.  Occasional  stimulation  and  frequent 
changing  of  treatment  hastens  the  healing  of  the  most 
chronic  ulcer.  A neglected  or  slow  ulcer  requires  daily 
treatment  if  recovery  is  desired. 

Unna’s  paste  bandages  are  prepared  as  follows: 
Heat  the  paste  to  liquefying  point  in  a double  boiler. 
Immerse  a loosely  rolled  gauze  bandage  in  this  until 
thoroughly  moistened.  Then  bandage  foot  and  leg  as 
if  applying  a starch  or  plaster  bandage.  Keep  the  limb 
quiet  until  the  bandage  is  dried. 

Cases  requiring  elastic  bandages  or  stockings  should 
be  referred  to  the  Supervisor. 

Care  of  Eye.  Removal  of  a foreign  body.  Turn  the 
lid  back  or  down,  remove  foreign  body  (if  not  imbedded) 
with  moist,  clean  cotton.  If  delicate  application  does 
not  remove  this,  bandage  the  eye  lightly  and  send  the 
patient  to  a physician  at  once.  The  eye  should  be 
bandaged  to  keep  the  patient  from  rubbing  it.  Do  not 
irrigate. 

Infected  Eyes  should  be  visited  daily.  If  the  family 
seems  irresponsible,  try  to  get  the  case  to  a hospital. 
Impress  upon  the  mother  daily  the  necessity  of  follow- 


48 


Visiting  Nurse  Manual 


ing  instructions  promptly  and  accurately.  Describe  the 
process  taking  place  in  the  eye  and  warn  her  of  the 
economic  as  well  as  mental  distress  that  total  or  par- 
tial blindness  may  cause  the  patient. 

Ophthalmia  neonatorum  is  a reportable  disease  and 
should  be  referred  to  the  Supervisor. 

When  giving  treatment  in  this  and  other  septic  cases, 
always  wear  rubber  gloves. 

Eyes  requiring  glasses  or  surgical  treatment  should 
be  carefully  followed  up.  While  the  burden  of  respon- 
sibility for  having  such  defects  corrected  falls  upon  the 
parents,  a nurse  should  be  sure  that  they  understand 
the  need  for  this  correction.  If  they  refuse  to  have  the 
treatment  given,  the  case,  with  doctor’s  diagnosis  and 
advice,  should  be  dismissed  to  the  Juvenile  Court. 

Discharging  Ears  are  always  suggestive  of  past  and 
future  trouble.  Delayed  treatment  may  precede  mas- 
toiditis and  will  eventually  cause  loss  of  hearing — a 
serious  handicap  to  a working  man  or  woman. 

No  nurse  should  dismiss  from  her  books  a child  hav- 
ing a discharging  ear  without  having  made  every  effort 
to  impress  upon  the  parents  the  importance  of  prompt 
action. 

When  parents  wilfully  neglect  troubles  of  this  sort 
a minor  child  may  be  reported  to  the  Humane  Society 
or  the  Juvenile  Court  for  protection. 

If  irrigation  is  ordered,  a fountain  syringe  is  better 
than  a hand  syringe.  It  should  be  hung  not  more  than 
6 inches  higher  than  the  ear  itself.  The  solution  should 
be  of  temperature  easily  borne  on  the  wrist;  the  shoul- 
der should  be  protected  by  a dressing  towel  and  the 
patient  taught  to  hold  a dressing  basin  himself. 

The  canal  and  outer  ear  should  be  thoroughly  dried 
by  soft  cotton  pledgets  after  any  irrigation. 

Bladder  Irrigation.  Keturn-flow  catheter  may  be 
obtained  in  loan  closet.  Fountain  syringe  should  be 
boiled  before  each  irrigation.  Cold  sterile  water,  boric 
or  saline  solution,  should  be  prepared  daily  and  left 
for  next  treatment. 


Medical  Nursing 

MEDICAL  NURSING 


49 


References — Maxwell  & Pope,  pp.  337-427. 

Rosenau — Preventive  Medicine  and  Hygiene. 

Sanders — Modern  Methods  in  Nursing,  pp.  439-471, 
387-439. 

Nursing  in  Communicable  Diseases. 

In  overcrowded  and  badly  managed  district  homes 
perfect  quarantine  seems  so  impossible  of  attainment 
that  there  is  danger  that  the  visiting  nurse  may  give 
but  half-hearted  and  incomplete  isolation  instructions. 
An  ignorant  disregard  of  infection,  an  old-time  belief 
that  all  children  must  sooner  or  later  have  the  diseases 
of  childhood,  and  a superstitious  fear  of  fresh  air, 
water  and  cleanliness  in  the  sick  room,  will  frequently 
be  encountered.  It  is  not  unusual  to  find  a scarlet 
fever  patient  on  a cot  in  the  kitchen  or  sharing  the 
bed  of  an  apparently  well  child.  Occasionally  a lying-in 
mother,  a .young  infant  and  a case  of  measles  or 
scarlet  fever  may  be  found  in  the  same  household.  Such 
cases  have  been  nursed  at  home — by  visiting  nurses — 
in  spite  of  seemingly  insurmountable  handicaps  and 
the  patients  all  dismissed  “well.” 

On  the  other  hand,  an  apparently  mild  attack  of 
diphtheria  or  whooping  cough  has  been  the  cause  of 
death  in  many  instances.  Because  a few  patients  have 
been  known  to  recover  when  every  sanitary  precaution 
was  apparently  defied,  hundreds  of  lives  have  been 
sacrificed  because  some  one  neglected  quarantine  rules. 
The  danger  of  violating  these  rules  should  be  repeatedly 
emphasized,  and  families  warned  that  the  Health  De- 
partment has  power  to  enforce  hospitalization  if  quar- 
antine is  impossible  or  broken.  Always  advise  and 
urge  hospital  treatment  whenever  it  is  difficult  to  estab- 
lish isolation  of  patient,  attendant  and  utensils.  Never 
make  light  of  contagion  in  a home  where  there  are 
susceptible  children,  and  do  not  make  it  too  easy  to 
care  for  contagious  cases  at  home. 

Unless  you  know  that  the  attending  physician  or  a 
former  nurse  has  reported  patient  and  diagnosis  to 


50  Visiting  Nurse  Manual 

Health  Department,  this  should  be  done  on  special 
form  post  card.  If  you  suspect  contagion  and  the  case 
has  not  been  reported  and  other  children  are  being 
exposed,  telephone  your  suspicions  to  the  Health  De- 
partment and  ask  that  an  inspector  be  sent  out. 

Nursing  and  Visits.  All  nursing  visits  to . contagious 
cases  by  general  nurses  should  be  made  at  the  end  of 
each  day.  A long-sleeved  gown  and  cap  should  be  car- 
ried to  each  case  and  worn  during  treatment.  Before 
donning  gown,  get  everything  needed  (solution,  tongue 
depressor,  cotton,  soap,  nail  brush,  etc.)  from  bag,  close 
it  and  leave  it  with  outside  uniform  on  porch  or  in 
room  away  from  patient.  Remove  cuffs,  roll  sleeves 
up  to  elbows,  prepare  hand  solution,  collect  everything 
needed  for  the  sick  room,  and  then  put  on  cap  and 
gown.  After  care  is  given,  disinfect  hands,  remove 
gown,  folding  it  so  that  inner  surface  is  not  contami- 
nated, and  put  in  safe  place  within  sick  room.  Dis- 
infect hands  a second  time  and  then  scrub  them  thor- 
oughly with  soap  and  water  and  brush.  Let  family  see 
you  scrub  up  and  tell  why  you  do  it. 

Explain  that  infection  follows  careless  contact  of 
attendant’s  hands  or  clothing  with  person  and  bedding 
of  patient,  and  have  her  wear  a long  apron,  an  old 
wrapper  or  a folded  sheet  over  house  dress  whenever 
she  goes  to  patient’s  bedside.  Teach  her  to  keep  this 
wrap  for  the  sick  room  only,  and  to  so  fold  or  hang  it 
up  that  the  inner  surface  remains  uncontaminated. 

Observe  the  following  precautions  and  teach  them  to 
attendant: 

Take  nothing  from  the  sick  room  that  has  not  been 
disinfected. 

Care  of  Hands.  Emphasize  care  of  attendant’s  hands 
and  need  of  thorough  scrubbing  after  disinfectant  is 
used.  Perhaps  the  safest  disinfectant  to  advise  for  the 
hands  is  creolin  or  cresol.  The  basin,  half  full  of  a 2 
per  cent  solution,  should  remain  just  outside  door  of 
sick  room  in  a safe  place.  Attendant  should  be  taught 
the  importance  of  using  the  disinfectant  after  every 
treatment,  no  matter  how  slight,  and  always  before 


Medical  Nursing 


51 


uninfected  articles  (door  knobs,  bureau  drawers,  trays, 
etc.)  are  touched.  This  is  difficult  to  teach,  for  too 
many  people  refuse  to  consider  it  worth  while  unless 
done  in  the  nursed  presence. 

Linen.  Have  a pail  or  wash  boiler  one-third  full  of 
cold  water  or  disinfectant  solution  inside  sick  room. 
Roll  soiled  linen  in  cloth  and  immerse  bundle  in  wash 
boiler.  This  should  be  carried  at  once  to  stove  and 
allowed  to  boil  before  linen,  is  handled.  Prompt  sterili- 
zation by  boiling  is  better  than  soaking  in  a disin- 
fectant. Too  much  precaution  cannot  be  exercised  in 
the  matter  of  leaving  disinfectants  in  district  homes. 

Dishes.  A large  saucepan  half  filled  with  cold  water 
should  be  kept  to  receive  medicine  glasses,  spoons,  cups, 
etc.,  from  sick  room.  Dishes  should  be  boiled  before 
being  rinsed  or  washed  at  sink.  All  uneaten  food 
should  be  wrapped  in  newspapers  before  being  carried 
from  sick  room,  and  then  burned. 

Excreta.  Expectoration  should  be  received  in  soft 
cloths,  which  should  be  placed  in  paper  bags  or  rolled 
in  clean  newspaper  and  burned  promptly.  Never  use 
basin  or  cup  for  slight  expectoration;  give  patient  old 
cloths.  Bedpans  and  urinals  should  contain  small  quan- 
tities of  2 per  cent  lysol  solution  or  chloride  of  lime 
5 per  cent  before  being  used  and  an  equal  quantity  of 
same  disinfectant  should  be  added  before  urine  or 
faeces  is  thrown  into  hopper.  All  bathing  water  should 
be  boiled  or  disinfected  before  being  discarded.  Permit 
toilet  to  be  used  only  for  properly  disinfected  waste 
material. 

Nose  and  Throat  Treatment.  Before  giving  nose  and 
throat  treatment  in  any  infectious  disease,  protect  your 
own  face  with  a mask  that  entirely  covers  mouth  and 
lower  half  of  nose.  This  mask  had  better  be  made  of 
paper.  A paper  napkin  folded  diagonally  may  be  se- 
curely pinned  to  the  hair  or  contagious  cap.  An  easier 
mask,  if  many  treatments  are  being  given,  may  be 
made  of  a diagonally  folded  doily-size  paper  napkin 
that  has  ear  loops  of  fine  bicycle  wire  in  two  corners. 
This  can  be  slipped  on  easily  and  is  less  confining  than 
a pinned  mask. 


52 


Visiting  Nurse  Manual 


Be  sure  that  patient's  hands  are  wiped  with  disin- 
fecting solution  after  each  throat  treatment  and  that 
the  tip  of  the  atomizer  is  well  wiped  with  95  per  cent 
alcohol  sponge. 

Sterilization  by  heat  is  the  best  method  of  disinfec- 
tion in  district  homes,  but  in  hot  weather  a large  fire 
may  heat  the  whole  house  for  hours,  or  there  may  be 
no  fuel  for  any  sort  of  fire.  Coal  and  wood  can  not 
be  used  too  freely,  but  disinfection  and  sterilization 
should  be  insisted  upon  for  the  protection  of  the  com- 
munity as  well  as  of  the  rest  of  the  family.  This 
expense  for  fires  is  another  reason  for  urging  hospital 
care. 

Care  of  the  Room.  Teach  damp  sweeping  and  dust- 
ing with  cloth  wrung  out  of  disinfectant.  Broom  and 
duster  should  remain  in  sick  room  until  case  ‘is  term- 
inated. 

Disinfection.  When  any  case  is  terminated,  whether 
or  not  special  fumigation  is  ordered  and  done,  room 
should  be  thoroughly  cleansed,  walls  wiped  down,  fur- 
niture, woodwork  and  floor  scrubbed,  bed  linen  and 
curtains  washed,  and  mattress  and  carpet  or  rug  sunned 
and  aired  before  room  is  occupied  by  other  members 
of  family. 

The  Chicago  Department  of  Health  has  issued  the  fol- 
lowing regulations  concerning  quarantine,  school  exclu- 
sion of  susceptible  children,  termination  of  case  and 
disinfection.  Placarded  means  that  a Health  Depart- 
ment warning  is  tacked  on  door  of  house  or  apartment. 

1.  Diphtheria.  Placarded. 

Quarantine  until  two  negative  cultures  have  been 
secured  on  two  consecutive  days  by  the  Health  Officer. 

School  exclusion  for  exposed  children  living  in  same 
apartment  until  quarantine  has  been  lifted. 

Disinfection — Health  Department. 

Antitoxin  can  be  secured  free  for  all  contacts  and 
all  positive  cases  at  the  various  state  antitoxin  sta- 
tions located  throughout  the  city. 


Medical  Nursing 


53 


2.  Diphtheria  Carriers.  Placarded. 
Quarantine  until  negative  culture  has  been  secured 
by  Health  Officer. 

3.  Scarlet  Fever.  Placarded. 

Quarantine  until 

a.  Termination  of  desquamation. 

b.  Cessation  of  all  discharge  from  ear  and  nose. 

c.  Disappearance  of  evidence  of  acute  inflammation 
of  tonsils,  usually  five  weeks  or  longer,  though  if 
b.  and  c.  are  satisfactory  at  the  end  of  five  weeks  a., 
desquamation,  may  be  disregarded. 

Disinfection  by  Health  Department. 

School  exclusion  as  in  diphtheria. 

4.  Measles.  Placarded. 

Quarantine — 2 weeks  maximum. 

School  exclusion  — susceptible  exposed  pupils  and 
teachers  eighteen  days. 

Disinfection — none. 

5.  Whooping  Cough.  Placarded. 

Quarantine — 5 weeks,  from  first  whoop  (for  2 weeks 
in  house  or  private  yard,  last  3 weeks  at  large  if  pa- 
tient wears  “whooping  cough”  sleeve-band  furnished 
by  Health  Department). 

Disinfection — none. 

6.  Epidemic  Poliomyelitis.  Placarded. 
Quarantine  — rigid  isolation  5 weeks,  windows 
screened. 

School  exclusion — until  quarantine  is  lifted. 
Disinfection — by  Health  Department. 

7.  Epidemic  Cerebro  Spinal  Fever. 

Isolation — at  least  2 weeks,  other  precautions  as  in 
Epidemic  Poliomyelitis.  (Not  placarded.) 

8.  Chicken  Pox. 

Quarantine — 2 weeks  or  until  through  scaling. 

School  exclusion — susceptible  children  2 weeks. 
Disinfection — none.  (Not  placarded.) 


54 


Visiting  Nurse  Manual 


9.  German  Measles. 

Quarantine — maximum  10  days. 

School  exclusion — susceptible  children  3 weeks. 
Disinfection — none.  (Not  placarded.) 

10.  Mumps. 

Quarantine — until  all  swelling  has  subsided. 

School  exclusion — susceptible  children  3 weeks.  (Not 
placarded.) 

Other  diseases  to  be  reported  to  Health  Department 
are: 

Tuberculosis  (all  forms). 

Typhoid  Fever — Milkman’s  placard  on  rear  door 
only. 

Streptococcus  Sore  Throat — Milkman’s  placard  on 
rear  door  only. 

Smallpox — All  cases  taken  to  City  Smallpox  Hos- 
pital. 

Ophthalmia  neonatorum 
Rabies 
Erysipelas 
Tetanus 


Not  placarded. 


11.  Erysipelas. 

Always  use  gloves.  Do  not  do  dressing  nor  give 
nursing  care  when  carrying  maternities  or  clean  sur- 
gical cases.  Observe  special  contagious  disease  precau- 
tions. 

Specific  Precautions.  Always  wear  rubber  gloves. 
In  an  emergency  a pair  may  be  purchased  in  the  neigh- 
borhood. Teach  the  family 

1.  To  keep  separate  utensils  (dishes,  etc.)  for  the 

patient. 

2.  The  importance  of  protecting  the  toilet  properly 

if  the  patient  is  allowed  to  go  to  a common 

bath  room. 

3.  Careful  disinfection  or  separate  sterilization  of 

all  bed  and  personal  linen. 


Medical  Nursing 


55 


Unless  thoroughly  disinfected  this  linen  should  never 
be  sent  to  a public  laundry  nor  given  an  ignorant 
laundress. 

On  the  second  visit  to  a case  of  this  sort  a contagious 
gown  should  be  carried  and  left  in  the  home.  Vaginitis 
cases  should  wear  pads,  which  should  be  burned  after 
removal.  In  bad  cases  of  this  type  some  physicians  de- 
sire to  have  the  pads  wrung  out  of  a 1 to  10,000  bichlor- 
ide solution.  Acute  venereal  cases  should  never  be 
handled  when  a nurse  is  carrying  maternities  and  clean 
surgical  dressings. 

Whenever  possible,  adults  should  be  taught  to  give 
their  own  treatment.  When  it  is  necessary  for  the 
nurse  to  give  mercurial  ointment  treatments,  gloves 
should  always  be  worn. 

13.  Typhoid  Fever. 

Transfer  to  hospital  if  possible.  Few  private  houses 
have  toilet  or  other  facilities  for  treating  typhoid  at 
home. 

Always  wear  a contagious  nursing  gown  if  care  is 
given  in  the  home.  Take  T.  P.  R.  and  give  daily  or 
twice  daily  general  care,  paying  particular  attention  to 
teeth,  back  and  hands. 

Mouth  should  be  cleansed  at  least  three  times  daily. 
(If  tooth  brush  is  used,  it  should  be  kept  immersed  in 
saturated  boracic  solution.)  This  solution  should  be 
changed  daily  and  the  receptacle  boiled.  (Explain  this 
detail  to  the  attendant.) 

To  prevent  pulmonary  hypostasis  the  position  of 
weak  or  delirous  patients  should  be  changed  occasion- 
ally from  back  to  either  side. 

Diet.  Unless  special  diet  is  ordered,  milk  (diluted 
p.  r.  n.  with  carbonated  or  lime  water)  is  most  easily 
borne  by  patient  and  prepared  by  attendant,  who  should 
be  taught  to  prepare  other  liquid  diet,  albumen  water, 
lemonades,  etc.,  and  to  keep  a bowl  of  finely  cracked  ice 
by  bed  side.  More  liberal  diet  is  given  many  typhoid 
patients  and  if  soft  diet  (toast,  eggs)  is  ordered,  be 
sure  that  family  does  not  give  a general  diet  instead. 


56 


Visiting  Nurse  Manual 


Disinfection  is  of  greatest  importance  and  exceedingly 
difficult  to  teach  lay  people,  hence  the  advisability  of 
prompt  hospital  care.  The  safest  as  well  as  most  inex* 
pensive  disinfectant  is  “chloride  of  lime”  (chlorinated 
soda,  bleaching  powder),  which  may  be  purchased  in 
10c  tins.  This  loses  strength  rapidly  if  exposed  to  air 
or  moisture,  consequently  it  should  be  kept  in  a closed 
jar. 

All  dishes,  linen  and  other  utensils  coming  in  contact 
with  patient  should  be  sterilized  by  boiling  or  complete 
immersion  for  one  hour  in  a 5 per  cent  chloride  of  lime 
solution. 

All  excreta  (urine,  faeces  and  sputum)  and  all  solu- 
tions used  for  patient  (mouth-wash  and  bathing  water) 
should  be  mixed  with  twice  their  volume  of  5 per  cent 
chloride  of  lime  solution  and  allowed  to  stand  one  hour. 
10  per  cent  formalin  solution  may  also  be  used  in  the 
same  manner  but  this  is  more  expensive,  (lib.  of  chlor- 
ide of  lime  to  2 gallons  of  water  makes  a 5 per  cent 
solution). 

Teach  all  of  these  precautions  and  observe  closely  to 
see  if  attendant  is  faithful  in  carrying  them  out. 

A visiting  nurse  caring  for  typhoid  cases  should  re- 
ceive anti-typhoid  serum  treatment. 

14.  Tuberculosis. 

Reference — Walters — The  Open  Air  or  Sanitorium 
Treatment  of  Pulmonary  Tuberculosis. 

(Chapters  1,  2,  7,  10,  15,  18,  22,  25.) 

In  caring  for  patients  suffering  from  pulmonary  tu- 
berculosis emphasize  frequently  the  lack  of  danger  to 
the  well,  if  both  patient  and  family  are  careful  to 
prevent  infection.  On  the  other  hand,  remember  that 
tuberculosis  is  not  a disease  that  may  be  controlled  or 
cured  in  the  average  home  and  never  advise  home  treat- 
ment when  good  institutional  treatment,  private  or  pub- 
lic, is  available.  In  congested  homes,  where  good  air  and 
food  are  out  of  the  question,  always  advise  institutional 
care.  If  there  is  no  suitable  hospital  or  sanitorium, 
get  in  touch  with  the  local  or  state  anti-tubercu- 


Medical  Nursing 


57 


losis  society  and  ask  their  advice  and  help.  When  pa- 
tients must  remain  at  home,  be  far-sighted  in  your 
planning;  plan  not  only  for  the  present  but  for  the 
future  as  well.  The  case  will  probably  be  on  your  books 
for  months  if  not  years. 

Home  Care.  Teach  the  patient  to  be  careful  to  cover 
his  mouth  with  paper  napkin  when  coughing  or  sneez- 
ing, to  expectorate  into  paper  napkin  or  cloths  that  can 
be  easily  destroyed,  to  use  his  own  dishes,  clothing, 
towels,  pillows,  bed,  etc.,  exclusively,  and  to  disinfect 
his  hands  frequently.  The  family  should  see  that  the 
patient's  room  and  lounging-place  ( porch,  roof  or  yard) 
is  comfortable  and  clean,  that  his  food  is  well  prepared 
and  properly  served  (and  the  prescribed  amount  eaten 
daily),  that  his  rest  is  not  disturbed  by  visitors  or  family 
and  that  he  is  spared  as  much  of  the  petty  annoyances 
of  daily  life  as  possible. 

This  program  is  not  as  utopian  as  it  sounds.  In  all 
but  the  very  poorest  homes,  much  of  it  can  be  carried 
out  if  the  family  is  earnest  and  unselfish  and  if  the 
nurse  will  plan  the  system  and  daily  routine  that  so 
many  households  lack.  A written  schedule  for  the  tu- 
berculosis patient's  day  should  be  drawn  up,  and  the 
family  should  be  encouraged  to  help  the  patient  make  a 
perfect  record. 

Teach  the  need  of  team-work  as  well  as  courage. 
Always  make  positive  suggestions,  never  sympathize 
pessimistically.  Tuberculosis  is  an  expensive,  exhaust- 
ing, discouraging  disease,  but  in  a large  percentage  of 
cases  it  can  be  cured.  Never  let  any  patient  lose  sight 
of  this  fact.  It  can't  be  cured  singlehanded.  Never  let 
the  family  lose  sight  of  this  fact.  And  remember  your 
own  responsibilty — to  instruct  repeatedly  and  carefully, 
to  report  to  Health  Department,  to  obtain  the  wisest 
form  of  relief  whether  in  home,  in  sanitorium  or  hos- 
pital and  to  maintain  an  intelligent  helpful  interest  in 
each  individual  patient  as  long  as  he  requires  your  aid. 

In  watching  for  suspicious  cases,  remember  that  the 
early  diagnosis  of  tuberculosis  is  based  on 

1.  History  of  exposure,  more  or  less  prolonged. 


58 


Visiting  Nurse  Manual 


2.  Symptoms  suggestive  of  tuberculosis  (particu- 
larly recurring  afternoon  rise  of  temperature;  with 
women  particularly  preceding  or  following  menses). 

8.  Tuberculosis  of  other  organs. 

4.  Examination  of  chest. 

5.  Tuberculin  test. 

6.  Tubercle  bacilli  in  sputum. 

Some  of  the  characteristic  symptoms  of  tuberculosis: 

1.  Persistent  lassitude,  fatigue,  weariness,  anae- 
mia, under  weight  or  loss  of  weight. 

2.  Nervous  symptoms — restlessness  and  irrita- 
bility. 

3.  Gastro-intestinal — loss  of  appetite,  dyspepsia. 

4.  Afternoon  or  evening  temperature. 

5.  Increased  pulse  rate  (unstability  of  pulse  char- 
acteristic of  tuberculosis  infection). 

6.  Sweats  or  tendency  to  perspiration  that  is  not 
normal. 

7.  Dry  cough. 

8.  Expectoration,  especially  in  morning. 

9.  Blood  spitting  (always  suspicious). 

Points  to  remember. 

Care  of  sputum: 

1.  The  best  method  is  to  burn. 

2.  Lysol  2 per  cent  (add  equal  volume  of  solution, 
mix  thoroughly;  allow  whole  to  stand  two  hours). 

3.  Carbolic  5 per  cent. 

Do  not  use  corrosive  sublimate. 

Discourage  use  of  handkerchief,  metal  or  paper 
sputum  cups. 

If  rubber  lining  is  used  in  pocket,  it  should  be  lined 
with  waxed  paper  so  folded  that  waxed  paper  and 
paper  napkins  may  be  burned  together.  If  napkins  are 
used  in  homes,  have  up-patients  carry  small  paper  bags 
(1-pound  size).  These,  with  the  used  napkins,  should 
be  burned. 


Medical  Nursing 


59 


Bed  patients  should  be  given  large  bags  of  heavy 
paper  or  newspaper  cornucopiae  that  may  be  pinned  to 
mattress  within  easy  reach  of  patient's  right  hand.  The 
opening  of  either  should  be  just  large  enough  to  receive 
crumpled  napkin  easily. 

In  homes  where  there  are  no  coal  stoves  the  napkins 
should  be  burned  in  the  furnace  or  in  wire  receptacles 
in  alley  or  yard.  Expert  disposition  of  expectoration 
in  its  moist  state  must  be  insisted  upon.  Dried,  pulver- 
ized sputum  is  the  real  menace  in  tuberculosis. 

Bedding.  Bedding  may  be  washed  with  family  supply 
if  patient  is  not  expectorating  much  and  is  properly 
careful.  Otherwise  treat  as  in  other  contagious  dis- 
eases. 

Dishes.  Warn  against  family  or  public  drinking  cup. 

Advocate  boiling  or  at  least  separate  washing  in  hot, 
soapy  water  of  all  dishes  used  by  patient. 

Clothing  should  be  frequently  aired  in  the  sunshine, 
together  with  blankets  and  rug  from  patient’s  room. 

Room.  Best  sleeping  room  in  house,  preferably  an 
end  room.  Must  have  sunshine.  Teach  someone  how  to 
keep  it  clean  and  bright  and  cheerful.  A flowering 
plant,  white  curtain  and  pictures  all  help. 

Rest.  Warn  convalescing  patient  against  danger  of 
decreasing  rest  without  orders. 

Diet.  (Reference,  Walter,  pp.  108-139;  237-261.) 
Don’t  put  a special  diet  in  any  home  where  the  ordinary 
food  supply  is  insufficient.  An  unselfish  patient  will  in- 
evitably share  it.  Tuberculosis  does  not  make  any  indi- 
vidual less  human.  Try  to  urge  or  force  institutional 
treatment  for  such  patients. 

Remember  that  an  excessive  increase  over  normal 
body  weight  is  not  desired,  but  the  average  patient 
should  eat  in  twenty-four  hours  three  generous,  some- 
what concentrated  meals,  with  a larger  proportion  of 
fat  than  is  required  in  the  diet  of  a well  person.  This 
fat  may  be  given  in  milk,  butter  and  its  substitutes,  oil 
and  meats.  Don’t  encourage  nibbling  between  meals. 


60 


Visiting  Nurse  Manual 


If  necessary  to  tempt  a failing  appetite,  advise  crackers 
and  milk,  or  eggnog  or  cocoa  that  is  largely  milk 
midway  between  meals  or  before  retiring.  Don't  place 
undue  emphasis  on  milk  and  eggs  unless  the  patient 
is  also  going  to  receive  meat,  vegetables,  fruits  and 
other  equally  agreeable  and  necessary  articles  of  food. 

Patients  are  seldom,  if  ever,  cured  by  an  insipid  diet 
of  eggs,  milk  and  county  supplies. 

Stimulants.  Alcohol,  strong  tea  or  coffee  are  counter- 
indicated.  Tea,  coffee  or  cocoa  may  be  given  if  served 
two-thirds  milk  or  cream. 

Relief.  Too  much  is  worse  than  none  at  all.  It  is 
useless  to  develop  dependence  and  indolence  in  people 
whose  mental  poise  enables  them  to  accept  relief  as  their 
perpetual  right.  Unless  a patient  is  faithful  in  his 
obedience  to  orders,  give  one  warning  and  then  have 
relief  stopped.  Recovery  from  tuberculosis  is  as  much 
the  patient's  business  as  it  is  the  community's.  When 
others  are  being  endangered  by  a tuberculous  patient's 
carelessness  or  indifference,  consult  every  available 
agency  (medical,  relief,  legal,  child-placing)  before 
making  a final  plan. 

If,  on  the  other  hand,  a patient  is  doing  his  best  to 
carry  out  instructions,  don't  let  co-operating  agencies 
lose  sight  of  this  fact. 

Nursing.  (Walters,  105-107.)  General  nursing  care  is 
indicated  when  patient  is  in  bed. 

Oil  rubs  are  frequently  ordered  for  emaciated  pa- 
tients. They  should  be  preceded  by  a warm  sponge  or 
an  alcohol  rub  and  then  given  with  gentle  friction. 

Unless  otherwise  ordered,  there  is  no  special  advan- 
tage to  be  gained  in  keeping  advanced  cases  in  bed  all 
day.  If  patient  is  strong  enough  and  desires  it,  it  is 
well  to  teach  the  family  to  get  her  up  for  a few  minutes 
night  and  morning  while  bed  is  being  made.  This 
change  of  position  often  insures  a quieter  night. 

Night  sweats  may  be  relieved  by  vinegar  sponges. 
Equal  parts  of  tepid  water  and  vinegar  should  be  used, 
with  no  friction.  As  these  sweats  usually  occur  when 


Nursing  of  Chronics 


61 


only  the  family  can  give  care,  a vinegar  sponge  might 
be  given  by  the  nurse  as  a demonstration  instead  of 
the  usual  bath  or  alcohol  rub. 

Coughing.  No  medication  of  any  description  should 
be  administered  or  advised  without  a physician’s  orders. 
A healed  lung  and  a fixed  craving  for  opium  is  worse 
than  tuberculosis.  Much  coughing  can  be  eliminated 
if  patients  are  taught  to  check  the  first  cough.  Hot 
water,  sipped  slowly,  will  often  control  painful  morning 
paroxysms  of  coughing.  Cold  compresses  over  the 
throat  sometimes  give  relief. 

Laryngitis.  Chipped  ice  held  in  mouth  just  be- 
fore nourishment  is  taken,  helps  patient  to  swal- 
low. Cold  liquids,  concentrated,  are  more  easily  taken 
than  hot.  Broth  or  beef  juice  should  not  contain  pepper 
and  but  a very  little  quantity,  if  any,  of  salt.  A throat 
spray  containing  cocaine  gives  relief,  but  this  should 
be  carefully  used  and  always  by  a physician’s  orders. 

Common  Colds.  Most  communicable  during  early 
stages.  Keep  patient  isolated  and  in  bed  three  days,  if 
possible.  Sequelae  serious.  Ascertain  secondary  cause 
(dust,  bad  ventilation,  improper  feeding,  long  hours), 
and  help  patient  to  overcome  this  tendency  by  more 
regular  living,  eating  and  sleeping. 

NURSING  OF  CHRONICS 

Care  of  the  Aged.  Whenever  giving  nursing  care  to 
old  people,  try  to  have  someone  watch  every  detail  that 
good  care  may  be  given  during  your  absence.  Old 
people,  as  a rule,  object  to  bathing  and  fussing;  they 
like  to  be  comfortable  but  not  too  clean.  Don’t  trouble 
them  with  a rigid  routine  or  a bed  made  hospital 
fashion.  See  that  the  pressure  areas  (heels,  elbows, 
backs,  etc.)  are  well  rubbed,  that  their  linen  is  clean 
and  that  their  diet  is  suitable  (nourishing,  somewhat 
concentrated  and  served  warm). 

Constipation  and  retention  of  urine  should  be  guarded 
against.  If  this  cannot  be  regulated  by  diet  and  amount 
of  liquids  taken,  the  physician’s  attention  should  be 


62 


Visiting  Nurse  Manual 


called  to  the  patient’s  need.  The  above  is  equally  true 
of  other  chronic  cases  (paralysis,  locomotor  ataxia, 
tuberculous  sinus,  rheumatism,  Bright’s  disease,  etc.). 
Our  chronics  (old  and  young)  need  our  most  gentle, 
considerate  care,  for  in  too  many  instances  the  visiting 
nurse’s  call  is  the  brightest  spot  in  their  lives.  Each 
patient  should  be  made  as  comfortable  as  possible. 
Special  pads,  cushions,  bed-rests,  etc.,  should  be  impro- 
vised for  helpless  patients.  Be  careful  not  to  accept 
any  condition,  even  of  long  standing,  as  incurable  until 
physicians  most  able  to  aid  each  type  of  case  have  been 
consulted. 

Pulmonary  Hypostasis.  Be  on  the  lookout  for  this  con- 
dition in  all  feeble  or  bed-ridden  cases,  whether  acute 
or  chronic.  Teach  family  how  safely  to  change  patient’s 
position,  even  when  condition  is  critical. 

NURSING  OF  CHILDREN 

The  nursing  of  children  is  one  of  the  hardest  prob- 
lems of  a visiting  nurse. 

Affectionate  parents  are  suspicious  of  baths,  treat- 
ments, dressings,  etc.;  indifferent  parents  will  rarely 
take  the  trouble  to  carry  out  any  orders  at  all. 

Some  children  requiring  delicate,  careful  treatments 
(eye  irrigations,  extensive  burn  dressings,  etc.)  are  so 
undisciplined  that  each  visit  is  torture  until  the  little 
patient  accepts  the  inevitable  or  becomes  accustomed 
to  the  treatment  and  the  presence  of  the  nurse.  An 
ability  to  tell  fairy  stories,  an  occasional  surprise  and 
an  unvarying,  gentle  firmness  are  the  best  methods  of 
meeting  this  opposition.  Never  let  parents  frighten 
children,  but  see  that  prescribed  amount  of  treatment 
is  given  as  ordered.  Let  families  see  that  the  child’s 
future  welfare  is  just  as  important  as  its  present 
pseudo-comfort. 

Urge  hospital  treatment  for  all  acute  cases  that  may 
suddenly  develop  disastrous  complications  or  infections, 
but  do  not  send  babies  and  little  children  if  their  treat- 
ment can  possible  be  given  at  home.  Poor  homes  are 
better  than  good  institutions  for  most  babies. 


Nursing  of  Children 


63 


Urge  bed  and  a quiet  room  for  all  cardiac  and  chorea 
cases.  Have  abnormally  acute,  fidgety  or  dull  children 
seen  by  children’s  specialists.  Be  sure  that  orthopedic 
apparatus  is  properly  adjusted  and  understood,  and 
that  patients  wearing  it  are  taken  at  proper  intervals 
to  clinics  or  the  physician’s  office. 

Watch  for  abnormalities  (bowlegs,  limps,  hunchback, 
facial  deformities,  decayed  teeth)  and  try  to  get  some 
attention  for  each  case  as  you  find  it.  Many  of  these 
children  (especially  cases  of  spinal  curvature,  paralysis, 
or  contracted  muscles)  require  special  corrective  gym- 
nastics that  can  be  obtained  if  patient  lives  near  a 
small  park  center  or  a school  gymnasium.  Report  the 
case  to  the  instructor  personally  and  enlist  his  sym- 
pathy and  instruction. 

On  the  other  hand,  remember  that  children  of  school 
age  are  being  watched  by  the  school  nurses,  therefore 
do  not  duplicate  nor  interfere  with  their  work. 

Pediculosis.  Saturate  hair  with  kerosene  and  olive 
oil,  equal  parts,  and  pin  in  towel  turban  for  the  night. 
In  the  morning  shampoo  with  hot  water  and  green  soap, 
and  use  fine  comb.  If  head  is  in  bad  condition,  have 
mother  cut  hair.  This  treatment  will  need  to  be  re- 
peated frequently,  but  mother  should  be  taught  to  do  it. 
Children  with  peduculi  or  nits  in  their  hair  are  refused 
at  all  summer  camps. 

Sore  Throat.  Never  use  gargle  until  after  physician 
has  seen  throat.  Isolate  patient.  Have  dishes  boiled. 
If  child  has  been  exposed  to  contagious  disease,  report 
case  to  physician  or  Health  Department. 

Tonsil  and  adenoid  cases  should  not  be  dismissed  until 
every  effort  has  been  made  to  get  advised  treatment 
carried  out.  After  the  operation  has  been  performed, 
caution  mothers  to  guard  against  night  mouth  breath- 
ing, for  this  habit  will  not  be  cured,  in  most  cases, 
simply  by  the  removal  of  the  obstructing  tissue. 


64  Visiting  Nurse  Manual 

TABLE  SHOWING  WEIGHT  AND  HEIGHT  FROM 
BIRTH  TO  THE  SIXTEENTH  YEAR. 


Weight,  Lbs.  Height,  In. 


*Age — 

Boys. 

Girls. 

Boys. 

Girls. 

Birth  

7.5 

7.1 

20.6 

20.5 

6 months 

16.0 

15.5 

25.4 

25.0 

12  months 

20.5 

19.8 

29.0 

28.7 

18  months 

22.8 

22.0 

30.0 

29.7 

2 years 

26.5 

25.5 

32.5 

32.5 

3 years 

31.2 

30.0 

35.0 

35.0 

4 years 

35.0 

34.0 

38.0 

38.0 

5 years 

41.2 

39.8 

41.7 

41.4 

6 years 

45.1 

43.8 

44.1 

43.6 

7 years 

49.5 

48.0 

46.2 

45.9 

8 years 

54.5 

52.9 

48.2 

48.0 

9 years 

60.0 

57.5 

50.1 

49.6 

10  years 

66.6 

64.1 

52.2 

51.8 

11  years 

72.4 

70.3 

54.0 

53.8 

12  years 

79.8 

81.4 

55.8 

57.1 

13  years 

88.3 

91.2 

58.2 

58.7 

14  years 

99.3 

100.3 

61.0 

60.3 

15  years 

110.8 

108.4 

63.6 

61.4 

16  years 

123.7 

113.0 

65.6 

61.7 

Never  dismiss  a child  needing  further  care  (surgical 
or  otherwise)  without  putting  the  case  in  your  time- 
book  (last  page)  in  order  that  another  attempt  may  be 
made  (three  or  six  months  later)  to  obtain  this  special 
treatment.  By  putting  name,  address  and  facts  on  last 
page  of  time  book,  another  nurse  in  that  district  will 
also  be  able  to  follow  the  case  later.  Always  write 
reason  for  not  securing  treatment  earlier  on  patient’s 
history  card. 


NURSING  OF  INFANTS. 

Infants  should  be  breast-fed  during  first  year.  In 
addition  they  may  be  given  farina  at  6 months;  soup 
(and  rice),  8 months;  one  year,  finely  minced  vegetables 

*Birth  to  5 years,  without  clothing — Holt;  5 to  15 
years,  with  clothing — Bowditch;  15  and  16  years,  with 
clothing — Holt. 


Nursing  of  Infants 


65 


— carrots  or  spinach, . V2  ounce.  Try  to  teach  mother  to 
nurse  baby  regularly  at  four-hour  intervals  during  day 
and  once  at  night  (6  and  10  a.  m.;  2,  6 and  10  or  11 
p.  m.)  The  baby  should  sleep  alone  and  not  be  picked 
up  whenever  it  cries.  Teach  mother  to  tub  and  sponge 
baby,  to  dress  warmly  but  not  too  heavily,  and  to  give 
plenty  of  water,  fresh  air  and  sunshine.  Help  her  plan 
for  at  least  one  outing  daily  and  to  give  its  morning  and 
afternoon  naps  in  a well  ventilated  room — not  in  a hot 
kitchen.  Mothers  quite  rational  about  fresh  air  for 
other  children,  are  afraid  of  its  effect  on  the  baby.  They 
should  be  taught  that  babies  resist  bad  air  less  easily 
than  do  older  children. 

Bottle  Fed  Babies.  Emphasize  care  of  bottles  and 
nipples;  of  cleanly  preparation  and  proper  care  of  milk, 
and  of  giving  a fresh  bottle  for  each  feeding.  Show 
mother  how  to  warm  bottle  without  overheating  milk 
and  to  test  temperature  of  milk  on  wrist  without  put- 
ting nipple  to  her  own  lips.  Encourage  her  to  hold 
baby  in  her  arms  when  feeding.  Teach  her  the  sig- 
nificance of  increased  weight,  crying,  stools  and  urine. 

Summer  Diarrhoea.  Stop  all  food.  Give  boiled  water 
until  further  orders.  All  diapers  should  be  placed  in 
a 2 per  cent  cresol  solution,  then  rinsed  in  cold  water 
and  boiled. 

Saline  Flushing.  Normal  salt  solution,  one  dram  to  a 
pint,  at  temperature  of  100  degrees.  Quantity  0 unless 
otherwise  ordered.  Protect  table  with  blanket  and  news- 
papers, and  use  newspaper  if  no  oilcloth  is  obtainable 
for  an  improvised  Kelly  pad. 

FLIES,  INSECTS,  VERMIN,  ETC. 

Fly  Breeding  Places  (manure  heaps,  loose  garbage 
and  very  dirty  yards  and  alleys)  should  be  reported 
to  the  Health  Department. 

Mosquito  netting  for  windows  will  be  provided  at  the 
discretion  of  the  Supervisor.  The  netting  should  be 
tacked  across  windows  on  the  outside  of  the  house.  In- 
side netting  is  often  in  the  way  and  too  easily  torn  off 
by  children  or  impatient  adults. 


66 


Visiting  Nurse  Manual 


Hot  Weather  Treatment.  Teach  the  family  to  cover 
bed  with  mosquito  netting.  The  following  methods  are 
practical  ' for  district  use: 

1.  Gather  round  an  ordinary  barrel  hoop  five  or  six 
widths  of  green  mosquito  netting,  stitched  together 
along  the  sides.  Cover  hoop  with  the  same  material 
and  suspend  frame  thus  made  from  hook  in  the  ceiling 
over  the  center  of  the  bed.  The  strips  of  netting  should 
be  long  enough  to  be  tucked  loosely  under  the  mattress 
on  all  four  sides  of  the  bed  and  full  enough  so  that  no 
unnecessary  strain  is  brought  upon  its  seams.  This 
makes  a tent-like  canopy  that  gives  the  patient  a sense 
of  air  and  space,  and  can  easily  be  pushed  aside  during 
treatment. 

2.  Half  hoops  may  be  securely  fastened  to  the  head 
and  foot  of  a small  bed  and  supported  by  a rod  or  stout 
cord  passed  from  the  center  of  one  hoop  to  the  center 
of  the  other.  Green  mosquito  netting  may  be  draped 
over  this  frame  and  tucked  in  on  all  four  sides  of  the 
bed.  This  net  can  be  lifted  to  one  side  when  any  treat- 
ment is  given.  These  bed  canopies  should  not  take  the 
place  of  window  screens,  but  in  congested  homes  where 
the  screening  is  improperly  done  and  people  are  con- 
stantly passing  through  the  rooms  they  will  afford 
secondary  protection  to  an  adult  or  very  sick  child. 

Baby  carriages  should  be  covered  with  a canopy  of 
double-width  mosquito  netting,  made  with  a running 
string  or  elastic  in  hem. 

Teach  each  family  that  flies,  mosquitoes,  rats,  mice 
and  other  house  vermin  are  disease  carriers,  often  at- 
tracted by  uncleanliness  of  person,  house  or  surround- 
ings. Enlist  their  help  in  keeping  a neighborhood  as 
clean  as  possible. 

House  Vermin  (Cock  Roaches,  Bed  Bugs).  A house 
overrun  with  these  should  be  reported  to  the  Health 
Department.  When  they  are  comparatively  few,  teach 
the  family  the  value  of  clean  sinks,  pantries  and  bed 
rooms.  Have  them  purchase  roach  powder  for  the 
kitchen  and  gasoline  for  bed  and  cracks  in  bed  room 
moulding  and  floor.  See  that  every  precaution  is  taken 


67 


Flies,  Insects,  Vermin,  Etc. 

in  using  either  powder  or  gasoline.  Emphasize  the 
danger  of  fire  in  the  use  of  the  latter.  Where  there  are 
tiny  children,  instruct  mother  to  use  powder  late  at 
night  and  to  wipe  it  up  carefully  in  the  early  morning. 

In  nursing  infectious  diseases,  especially  typhoid  and 
tuberculosis,  every  possible  precaution  should  be  taken 
to  keep  flies,  mosquitoes  and  other  vermin  out  of  the 
sick  room. 

Never  have  gasoline  used  unless  the  patient  is  in 
another  room.  When  the  patient  is  in  infested  bed  and 
no  other  bed  is  available,  use  a hot  lysol  solution, 
strength  1-20,  and  apply  this  to  bedstead,  corners  of 
mattress,  etc.  Repeated  cleansing  of  bed  in  this  man- 
ner will  aid  in  eliminating  the  above  condition.  Home- 
made apparatus  (bed  rests  and  tables)  should  be  in- 
spected daily.  Wheel  chairs  should  be  inspected  fre- 
quently and  occasionally  washed  with  lysol  solution. 

When  bed,  bedding,  chairs  and  garments  seem  to  be 
infested,  the  whole  room  should  be  thoroughly  sealed 
and  fumigated  with  sulphur.  (Sulphur  is  a good  in- 
secticide, but  a poor  germicide — Rosenaw.)  After  a 
sulphur  fumigation  the  room  should  be  thoroughly 
cleaned  and  inspected  before  anyone,  sick  or  well,  is 
allowed  to  sleep  in  it.  This  can  be  done  by  family  if 
well  instructed. 

If  the  vermin  is  confined  to  one  room  and  the  family 
willing  to  do  the  work  well,  the  condition  need  not  be 
reported  to  the  Health  Department.  Rooms  of  chronic 
patients,  if  neglected  for  any  length  of  time,  furnish 
breeding  places  for  all  sorts  of  vermin. 

INSURANCE  AND  INDUSTRIAL  NURSING 

The  general  visiting  nurses  give  care  to  the  industrial 
policy  holders  of  the  Metropolitan  Life  Insurance  Com- 
pany, to  the  members  of  the  Royal  Arcanum  Hospital 
Fund  and  to  employes  whose  firms  desire  to  pay  for  the 
services  of  the  Association.  A visiting  nurse  calling 
on  any  of  the  above  beneficiaries  should  explain  at 
whose  request  and  expense  she  has  come.  No  service 
money  is  ever  asked  or  accepted  from  these  patients. 


68 


Visiting  Nurse  Manual 


Metropolitan  Life  Insurance  Nursing  Service. 

When  making  a first  call  on  a policy  holder,  ask  to 
see  the  policy  to  secure  or  verify  the  policy  number  and 
date  of  issue,  and  to  assure  yourself  that  the  insured 
is  entitled  to  the  company's  nursing  service. 

If  the  patient  is  carrying  more  than  one  policy,  take 
number  and  information  from  any  industrial  policy 
more  than  one  year  old. 

All  industrial  policy  holders,  with  the  two  following 
exceptions,  are  entitled  to  a certain  amount  of  nursing 
service. 

Exceptions. 

1.  Pregnant  and  lying-in  women  whose  policies 

are  less  than  one  year  old. 

2.  Holders  of  policies  on  which  policy  number  is 

followed  by  letter  “A”  (indicating  ordinary 
life);  by  letter  “C”  (indicating  Intermediate); 
by  letters  “SC”  (indicating  Special  Class). 

All  policies  of  the  various  assumed  companies  (desig- 
nated by  the  other  letters  than  the  above  after  the 
policy  numbers)  are  industrial  and  entitled  to  nursing 
care. 

All  paid-up  industrial  policy  holders  75  years  old  and 
older  are  entitled  to  nursing  service. 

Physician.  No  case  may  be  carried  for  more  than 
one  visit  unless  there  is  a physician  in  attendance. 

Number  of  Visits.  The  number  of  visits  and  amount 
of  nursing  care  up  to  the  twenty-fifth  visit  is  left  to 
the  judgment  and  discretion  of  the  nurse  in  all  but 
maternity  cases. 

Normal  maternity  cases  whose  policies  have  been  in 
force  more  than  one  year  may  receive  nursing  care  at 
the  expense  of  the  company.  When  a maternity  patient 
requires  more  than  eight  post-natal  visits,  the  reason 
for  the  need  should  be  stated  on  the  card.  Cases  of 
complicated  pregnancy  (albuminuria,  placenta  praevia, 
prolonged  vomiting,  etc.)  may  receive  as  many  visits 
as  the  gravity  of  the  situation  indicates.  (As  the  com- 


Insurance  and  Industrial  Nursing  69 

pany  pays  for  no  visits  to  uninsured  persons,  new-born 
babies  are  cared  for  at  the  expense  of  the  Association 
or  of  their  parents,  as  conditions  warrant.) 

Never  make  unnecessary  calls  because  the  patient 
desires  to  see  you  for  some  trivial  reason.  If  postal 
cards  are  sent  too  frequently,  make  the  one  visit  indi- 
cated and  dismiss  the  case. 

Number  of  Patients  in  Family.  If  you  find  several 
patients  in  one  household,  all  insured  and  suffering 
from  the  same  disease,  but  in  need  of  advice  rather 
than  of  actual  nursing  service,  make  out  one  report 
card  for  each  patient. 

Make  the  instructions  of  your  first  call  include  each 
patient,  specially,  but  when  making  additional  instruct- 
ive visits  to  that  household,  record  them  as  visits  to 
one  patient,  rather  than  as  several  visits  to  several 
patients  in  the  same  family  at  one  time.  As  the  pa- 
tients recover  and  are  dismissed,  all  but  one  case  will 
have  received  two  visits,  one  when  each  case  was 
opened  and  one  when  the  cases  were  dismissed,  all 
intervening  instructive  visits  should  be  made  and  re- 
corded as  being  made  to  but  one  patient. 

On  the  other  hand,  if  you  find  several  patients  in  one 
household  requiring  personal  nursing  service,  make  out 
a report  card  for  each  patient  and  record  the  necessary 
nursing  visits.  For  example:  Six  ambulatory  cases  of 
whooping  cough  might  require  weekly  visits  for  five 
weeks.  On  the  card  of  the  first  patient  should  be  re- 
corded five  instructive  visits;  on  the  cards  of  the  other 
five  children  should  be  recorded  two  visits  each.  Patient 
suffering  from  scabies,  pediculosis,  la  grippe,  measles, 
pneumonia  or  any  other  disease  requiring  individual 
nursing  service  should  each  receive  a personal  visit  as 
frequently  as  condition  warrants. 

An  interested  nurse  will  always  include  every  needy 
member  of  a family  in  her  instructions,  whether  she 
is  especially  paid  to  do  this  or  not;  therefore,  instruct 
some  responsible  person  in  each  household  in  whatever 
details  are  necessary  to  restore  any  member  to  better 
health. 


70 


Visiting  Nurse  Manual 


New  Case.  A new  case  is  one  never  on  the  books 
before  or  one  dismissed  in  a previous  month  or  year. 

Reopened  Case.  A reopened  case  is  one  dismissed 
during  the  current  month  and  reopened  during  that 
same  month  as  again  in  need  of  care.  If,  however,  a 
case  is  dismissed  on  the  23rd  and  taken  again  on  the 
26th,  it  should  be  classed  as  a new  case  and  the  usual 
procedure  with  new  cases  followed,  as  our  fiscal  month 
begins  on  the  26th. 

Closed  Case.  A closed  case  means  a dismissed  pa- 
tient whether  closed  a week  or  a year  ago. 

Records.  The  following  records  are  required: 

1.  Mailing  card  (postal)  or  report  card.  Postals  are 
supplied  to  policy  holders  and  mailed  by  them  when 
nursing  service  is  needed  in  their  household. 

Report  cards  are  similar  forms  but  are  filled  out  by 
nurse  for  patients  found  in  district,  telephoned  in  or 
referred  by  other  agencies. 

Information  is  identical  on  both  forms  and  if  correct 
the  following  items  should  be  red-checked  by  nurse  mak- 
ing first  visit:  name,  age  and  policy  number.  Each 
item  red-checked  by  nurse  making  first  visit  indicates 
that  it  has  been  verified  by  visiting  nurse.  It  is  just 
as  important  that  a nurse  should  red-check  these  three 
items  on  a report  slip  written  by  herself  as  it  is  that 
she  should  red-check  the  items  on  a mailing  card  written 
by  a patient  or  an  agent.  This  is  of  particular  im- 
portance when  postal  is  badly  written.  It  is  better  to 
rewrite  the  postal  card  if  it  is  very  illegibly  written. 
Whenever  a card  is  rewritten,  clip  old  and  new  cards 
together  and  turn  in  both  forms. 

Always  verify  carefully: 

1.  Name.  (For  difficult  foreign  names,  ask  someone 
to  spell  or  write  names  several  times  if  necessary. 
Print  first  letter  of  surname.)  If  patient  is  a woman 
who  has  been  married  since  taking  out  her  policy,  write 
married  surname  first;  follow  this  with  the  maiden 
name  as  it  appears  on  the  face  of  the  policy  (e.  g., 
for  Mrs.  Henry  Smith,  write  Smith,  Sarah  Jones). 


Insurance  and  Industrial  Nursing  71 

Address.  Do  not  abbreviate  name  of  street. 

Age  next  birthday  (calculate  from  face  of  policy). 

Sex.  Write  word  “male”  or  “female.” 

Color.  Write  word  “white”  or  “colored.” 

Physician.  Give  initials  and  office  address.  (Do  not 
write  “Brown,”  “corner  State  and  Madison.”) 

Case  Number  is  assigned  each  new  case  taken  on 
during  year,  is  added  to  card  at  Main  Office  and  used 
on  every  form  written  for  this  patient  until  case  is 
dismissed.  It  is  re-assigned  to  any  patient  dismissed 
and  taken  on  during  same  month;  and  should  be  entered 
opposite  patient’s  name  on  time  book  of  district. 

All  open  report  cards  must  be  turned  in  to  Super- 
visors on  the  morning  of  the  26th.  If  report  card  is 
being  held  for  Superintendent  or  Agent’s  0.  K.,  this 
must  be  reported  to  Supervisor  on  morning  of  26th. 

No  mailing  card  or  report  slip  should  be  sent  to  the 
Main  Office  for  any  reopened  case  or  for  any  case  being 
visited.  (Occasionally  a parent  or  an  agent  believes 
that  a carried  case  should  be  visited  oftener  than  the 
nurse  deems  necessary,  hence,  the  receipt  of  mailing 
cards  on  open  cases.) 

Policy  Number  should  be  taken  by  nurse  from  face  of 
policy.  It  should  be  copied  carefully  and  twice  verified. 
If  policy  has  been  wet  and  number  is  blurred  or  ob- 
scure, write  what  seems  to  be  the  correct  number  and 
at  foot  of  card  make  note  of  figures  that  are  difficult 
to  decipher. 

If  family  is  unwilling  to  display  policy,  explain 
importance  of  getting  correct  number  for  your  report. 
(Simple  people  are  often  suspicious  and  think  that  the 
nurse  wants  to  take  the  policy  away  or  change  its 
value.  Tell  such  people  that  verification  is  needed  to 
show  that  only  policy  holders  are  receiving  the  benefits 
of  this  nursing  service;  that  number  in  agent’s  receipt 
book  is  occasionally  incorrect;  that  nothing  is  deducted 
from  the  policy  when  care  is  given,  and,  last,  that  you 
cannot  return  unless  you  see  the  policy  number  yourself. 
Each  case  may  require  different  handling,  but  a tactful 
nurse  generally  wins  her  point.) 


72 


Visiting  Nurse  Manual 


If  policy  is  not  in  home  and  family  say  it  is  in  another 
city,  in  a safety  deposit  vault  or  with  a relative,  make 
note  to  this  effect  on  card  and  return  it  to  the  Metro- 
politan Life  office  for  the  Superintendent's  or  Agent's 

O.  K.  Never  red-check  a policy  number  or  any  item  on 
a mailing  card  or  report  slip  unless  you  personally 
have  verified  it. 

Kind  of  Policy.  Industrial  only. 

Date  of  issue — take  from  face  of  policy. 

Birthplace  of  policy  holder,  not  of  parent. 

District — means  Metropolitan  Life  district,  of  which 
there  are  twelve  in  Chicago:  (Chicago  North,  Chicago 
South,  Englewood,  Oakland,  Dearborn,  Humboldt,  Lake 
View,  Calumet,  Roseland,  Chicago,  Garfield  and  North 
Shore.) 

Agent  and  debit  number  are  both  helpful  facts  in 
tracing  incorrect  policy  numbers,  but  are  required  when 
policy  number  has  to  be  0.  K.'d  by  agent  who  collects 
the  premium. 

After  card  is  properly  filled  and  every  item  is  red- 
checked,  write  words  “first  visit"  with  date,  and  sign 
your  name  along  left  end  of  card  (e.  g.,  First  visit, 
2-3-14,  H.  L.  White).  Then  clip  card  to  daily  report 
and  turn  in.  These  cards  are  mailed  to  Registrar  in 
Main  Office  and  by  her  to  New  York  office  of  the  Metro- 
politan Life  Insurance  Company.  (All  incorrect  cards 
are  returned  to  Chicago  for  corrections  and  the  time 
of  at  least  eight  people  wasted  if  this  is  rendered  neces- 
sary.) 

Delayed  Cards.  If  a report  slip  is  more  than  three 
days  in  getting  to  the  Main  Office,  reasons  for  the  delay 
should  accompany  the  card. 

History  Cards.  On  receipt  of  the  mailing  card,  the 
Registrar  assigns  it  a case  number,  transfers  all  in- 
formation on  it  to  a patient's  history  card  and  mails 
postal  to  New'  York.  This  history  card  is  then  mailed 
to  the  substations  and  kept  on  file  until  the  patient  is 
dismissed. 


Insurance  and  Industrial  Nursing  73 

At  the  end  of  the  month  all  open  cases  should  be 
sent  to  the  Main  Office  with  the  monthly  report.  In 
“Treatments”  space  on  each  card  should  be  noted  the 
month  and  number  of  visits  (e.  g.,  June  6). 

N.  B.  Never  change  the  number  of  visits  recorded 
for  a former  month.  If  you  discover  a mistake,  consult 
the  Registrar  before  taking  any  action.  When  patient 
is  discharged,  the  date  of  last  visit,  condition  on  dis- 
charge and  total  number  of  visits  should  be  carefully 
recorded. 

The  data  asked  on  the  history  card  is  important. 
Every  item  should  be  filled  in  correctly.  If  you  cannot 
obtain  certain  items,  give  reasons  at  foot  of  card  or  in 
special  note. 

Occupation.  If  patient  is  not  working,  give  last  occu- 
pation. 

Diagnosis.  In  writing  diagnosis  on  history:  cards, 
put  the  diagnosis  in  the  proper  space.  All  explanatory 
notes  as  to  cause,  condition,  symptoms,  refusal  of  doctor 
to  give  give  better  diagnosis,  should  be  put  in  the 
remark  space.  Do  not  insert  more  information  in  either 
the  “Diagnosis”  or  “Complication”  space  than  can  be 
written  legibly.  Do  not  make  the  mistake  of  putting 
in  a complication  such  as  dropsy,  gangrene,  infection, 
etc.,  as  a diagnosis.  If  a medical  diagnosis  is  given 
and  surgical  treatment  ordered,  explain  why  (in  re- 
marks space),  if  bed  sore,  vaccination,  local  infection, 
etc.,  make  surgical  treatment  necessary. 

If  no  diagnosis  can  be  obtained  for  a patient  visited 
but  two  or  three  times,  state  symptoms.  No  patient 
should  be  carried  indefinitely  unless  a diagnosis  has 
been  made  by  attending  physician. 

Diagnosis  of  Open  Cases.  All  open  cases  reported 
at  close  of  month  must  state  symptoms  if  no  diagnosis 
has  been  made.  The  only  exception  to  this  rule  is 
when  the  patient  is  dismissed  after  one  call.  If  the 
patient  is  not  found  at  home  by  the  nurse  or  for  obvious 
reasons  does  not  need  further  nursing  care  or  invests 
gation,  the  symptoms  may  be  omitted  from  the  card. 


74 


Visiting  Nurse  Manual 


Number  of  Visits  should  be  filled  in  only  when 
patient  is  dismissed.  Give  total  number  of  visits,  not 
number  month  by  mpnth. 

Treatment.  Treatment  is  to  be  given  for  every  pa- 
tient visited  more  than  twice.  If  “advised,”  specify 
nature  of  advice. 

Whenever  remarks  pertinent  to  the  case  require  more 
space  than  is  allotted  on  mailing  or  history  cards  in 
“Remarks”  space,  a note  should  always  be  clipped  to 
card. 

Partial  History  or  Twenty-five  Visit  Card  (yellow 

slip)  should  be  filled  in  detail  and  sent  to  Main  Office 
immediately  after  the  twenty-fifth  visit  to  patient.  In 
order  to  send  card  in  promptly,  the  attending  physician 
should  be  asked  before  the  twenty-fifth  visit  how  much 
longer  he  deems  nursing  care  necessary.  In  writing 
this,  be  careful  to  denote  frequency  as  well  as  length 
of  service  estimated  (daily  visits  for  one  week,  bi- 
weekly visits  for  three  months,  etc.).  These  partial 
history  cards  are  sent  to  New  York  and  the  usual  care 
may  be  given  the  patient  until  further  instructions  are 
sent  out  by  the  Registrar. 

Home  condition  is  asked  on  all  open  cases;  designate 
this  by  use  of  terms  “Good,”  “Fair”  or  “Bad.” 

(In  inspecting  for  this,  differentiate  between  condi- 
tions under  tenants’  control  and  those  controlled  by 
owner  of  property.) 

Good — Plumbing  in  order,  adequate  light  and  air,  clean 
walls  and  ceilings.  House  dry  and  in  good  repair. 
Halls  and  stairways  light  and  ventilated.  Three 
hundred  cubic  feet  of  air  per  occupant. 

Fair — Rooms  clean,  plumbing  in  order,  every  room  ven- 
tilated from  outside,  light  enabling  one  to  read 
ordinary  print  in  daytime  without  artificial  light. 
Disorder  due  to  bad  housekeeping  rather  than  to 
landlord’s  neglect. 

Bad — Damp,  dark,  no  or  poor  ventilation,  requiring  arti- 
ficial light  during  day.  Walls  and  ceiling  very 
dirty.  Rooms  in  poor  repair.  Plumbing  out  of 
order  (toilet  not  flushing,  faucet  dripping,  wood- 
work around  pipes  decayed,  pipes  leaking,  vaults). 
Bad  household  management. 


Insurance  and  Industrial  Nursing  75 

Never  make  erasures  on  or  copies  of  history  cards. 
Send  original  card  with  corrections  on  other  paper  to 
Registrar.  Do  not  take  for  granted  that  the  Registrar 
or  New  York  will  understand  any  omissions.  Write  all 
necessary  explanations  plainly. 

Industrial  Nursing.  Term  used  to  designate  work 
done  at  shops  or  in  the  home  for  workers  whose  em- 
ployers bear  the  expense  of  the  nursing  service.  In- 
dustrial nursing  may  be  done  by  a nurse  who  devotes 
her  whole  time  to  the  employes  of  one  establishment 
or  by  the  district  nurse  who  makes  occasional  visits 
at  the  request  of  a firm.  Industrial  nurses  (full  time) 
arrange  their  work  to  best  advantage  in  each  district. 
As  a rule,  the  nurse  reports  at  11:30  a.  m.  and  until 
1:00  or  1:30  holds  dispensary  or  office  hours  for  con- 
sultations and  minor  dressings. 

Physicians.  All  medical  and  surgical  work  done  in 
the  homes  or  at  plants  is  done  under  a physician's 
orders.  If  the  plant  has  no  resident  or  attending  physi- 
cian, all  p.  r.  n.  dressings  and  medication  (iodine,  boric 
dressings,  aromatic  spirits  of  ammonia,  cathartics,  etc.) 
should  be  given  in  accordance  with  the  standing  orders 
of  a physician  authorized  by  the  firm.  This  cannot  be 
too  carefully  followed.  Plant  dressings  and  medica- 
tions, however,  are  only  a part  of  the  work.  Many 
employes  come  for  advice  concerning  their  teeth,  eyes, 
throats  or  general  condition,  and  need  to  be  referred 
to  other  agencies  (hospitals,  dispensaries,  etc.)  for  aid. 
Before  referring  such  patients,  get  in  touch  with  the 
physician  or  agency  from  whom  they  have  been  receiv- 
ing advice. 

Whenever  an  employe  or  his  family  requires  aid 
(medical  or  material),  report  case  to  firm  representa- 
tive before  asking  aid  of  a relief  society,  a hospital,  etc. 

Dismissed  Cases.  Patients  in  need  of  further  care 
to  whom,  for  any  reason,  the  industrial  nurse  may  not 
return,  should  be  dismissed  to  the  general  visiting 
nurses. 

Reports.  Each  industrial  nurse  keeps  a time  book 
and  renders  a monthly  statistical  report  to  the  Asso- 
ciation, a duplicate  of  which  is  mailed  to  the  firm.  A 


76 


Visiting  Nurse  Manual 


written  statement  giving  the  amount  and  kind  of  work 
done  during  the  month  is  also  sent  to  the  Main  Office, 
In  addition,  each  nurse  keeps  on  file  certain  printed 
records  for  each  patient,  which  are  usually  required 
by  the  firm.  A daily  report  (written  or  verbal)  is 
given  the  physician  or  other  representative  of  the  firm. 

New  Calls  are  received  from  physician,  foremen, 
superintendent,  other  employes.  The  type  of  home 
work  depends  on  the  desires  of  the  firm.  If  the  nurse 
is  able  to  care  only  for  the  patient,  rather  than  for  any 
member  of  his  family,  others  requiring  care  should  be 
referred  to  the  general  nurses.  Certain  forms  of  benefit 
associations  and  group  insurance  give  nursing  service 
only  to  the  beneficiaries.  In  these  instances  industrial 
nurses  should  work  very  closely  with  other  local  public 
health  nurses. 

Welfare  Work  is  a much  abused  term.  Anything 
which  increases  an  employe’s  efficiency  is  a decided  asset 
to  both  force  and  firm.  To  ensure  freedom  from  mental 
or  physical  suffering  is  relief  wisely  administered. 
Industrial  nurses  should  understand  initial  symptoms 
of  occupational  diseases,  sanitation  of  factories  and 
mills,  and  all  first  aid  treatment.  In  addition,  the 
methods  of  loan  sharks,  of  garnisheeing  wages,  of  pur- 
chase on  installment  basis  and  of  cashing  checks  or 
granting  credit  to  working  men  should  be  studied.  A 
great  deal  of  worry  and  subsequent  ill  health  can  be 
avoided  if  the  nurse  is  a friendly  adviser,  as  well  as 
an  administrator  of  minor  remedies. 

Industrial  nurses  should  be  careful  to  give  relief 
(advise,  drugs  or  aid)  wisely.  Workers  should  be 
encouraged  to  remain  independent,  to  aim  at  good 
standards  and  regular  habits.  A girl  constantly  asking 
for  headache  powders  needs  a careful  physical  exam- 
ination; a man  always  losing  a little  time  needs  more 
than  advise  regarding  his  diet  and  sleep  or  smoking. 
A nurse  whose  duties  involve  less  nursing  and  more 
so-called  welfare  work  is  under  a greater  obligation  to 
study  each  case  carefully  and  to  advise  constructively. 
The  first  material  aid  given  a working  man  may  help 
him  retain  his  independence  or  lose  it. 


SUBSTATION  DETAIL. 

Hours,  12:30 — 1:30  p.  m.  Nurses  report  in  person 
daily,  except  on  half  days  and  when  excused  by  Super- 
visor. Each  nurse  not  making  substation  should  tele- 
phone by  1 o'clock  for  instructions,  new  calls,  etc.  If 
unavoidably  detained  in  her  district,  a nurse  should 
telephone  and  not  try  to  make  substation  after  1:30. 
If  for  any  reason,  the  substation  cannot  be  reached 
by  telephone,  notify  the  Main  Office. 

This  noon  hour  is  used  for  clerical  work,  telephoning, 
conferences  with  Supervisor,  receiving  new  calls,  read- 
ing bulletin  board,  replenishing  bag  supplies,  etc. 

Half  Day.  Every  nurse  is  given  one  half  day  each 
week.  This  is  assigned  by  the  Supervisor,  but  may  be 
given  on  Monday  and  Saturday  only  by  special  request. 
No  new  calls  are  assigned  to  nurses  on  half  days,  but 
old  calls  (except  in  twice-daily  cases)  must  be  made 
before  the  district  is  left.  When  the  work  permits,  the 
half  day  begins  at  1 o'clock. 

The  usual  daily  report  should  be  written  and  turned 
in  for  all  Sunday  work  in  the  districts. 

Supplies.  All  bag  supplies  are  kept  at  the  substa- 
tions. Before  taking  fresh  linen  (bags,  linings,  towels, 
etc.),  turn  in  soiled  linen  for  laundry. 

Always  scrub  up  before  handling  fresh  linen,  gauze 
or  cotton.  Never  carry  partly  filled  bottles  of  lysol, 
alcohol,  etc.,  for  emergencies  in  district  work  must  be 
anticipated. 

Do  not  carry  more  drugs  or  other  odds  and  ends  than 
you  are  using. 

Avoid  letting  your  bag  become  a catch-all. 

Old  Linen  may  sometimes  be  obtained  at  the  sub- 
stations. Use  this  economically  and  wherever  possible, 
interest  your  friends  in  collecting  this  for  you.  Nothing 
so  enables  you  to  make  a chronic  patient  with  painful 


78 


Visiting  Nurse  Manual 


dressings  comfortable,  but  so  much  is  being  used  con- 
stantly that  we  must  never  lose  a chance  to  ask  for  it. 
Sheets,  pillow  slips,  table  linen  and  nightgowns  are 
especially  serviceable. 

Clothing.  Occasionally  clothing  for  men,  women  and 
children  is  sent  into  the  substation.  These  articles 
should  be  given  wherever  they  will  do  the  most  good, 
but  never  give  so  frequently  to  the  same  family  that 
its  members  will  begin  to  expect  clothing  from  the 
visiting  nurse.  Our  relief  giving  is  incidental.  We 
give  away  old  clothing  simply  because  it  is  given  us 
and  we  know  a family  in  need  at  that  particular 
moment.  Always  explain  in  giving  clothing  how  you 
happen  to  have  that  especial  outfit  to  give  away. 

Loan  Closets  and  Loan  Book.  Loan  closets  contain 
articles  needed  during  illness  in  many  of  our  homes  and 
may  be  loaned  to  any  reliable  family.  If  you  have 
reason  to  believe  that  the  articles  will  be  pawned  or 
misused,  don’t  loan  them.  When  promising  loan  closet 
supplies,  leave  written  instructions  of  substation,  ad- 
dress and  hours,  and  arrange  to  have  someone  (family 
or  neighbor)  call  at  noon  to  get  them. 

Every  article  loaned  should  be  recorded  in  loan  book, 
dated  and  signed  by  nurse  making  entry. 

Every  nurse  lending  supplies  is  responsible  for  their 
return  and  should  record  them,  with  correct  date,  over 
her  signature  in  the  loan  book  kept  at  the  substation 
for  this  purpose.  When  articles  are  returned,  date 
and  condition  should  be  entered  on  same  page.  This 
book  is  inspected  monthly  by  the  Supervisor  and  an 
accounting  asked  of  all  articles. 

Whenever  a nurse  is  assigned  to  a new  district  she 
should  go  through  the  loan  book  to  see  how  many  arti- 
cles are  loaned  in  that  district. 

Loan  closet  supplies  include 

Linen — Sheets,  pillow  cases,  contagious  gowns  and 
caps,  nightgowns. 

Rubber  Goods — Rings,  draw  sheets,  ice  caps,  hot 
water  bags. 

Utensils — Bed  pans,  urinals,  douche  pans. 

Wheel  chairs. 


Substation  Detail 


79 


Linen  loaned  to  patients  may  be  returned  rough  dried, 
but  should  always  be  clean.  It  should  be  sent  to  the 
laundry  before  being  returned  to  the  shelves. 

Rubber  goods  should  be  sterilized  and  cleansed  thor- 
oughly. 

Wheel  chairs  need  not  be  returned  to  the  substation, 
but  may  be  sent  from  one  house  to  another  as  soon  as 
the  first  patient  is  through  with  it. 

Blankets  are  sometimes  loaned  to  patients,  but  their 
return  is  seldom  or  never  asked.  If  returned,  they 
should  be  sent  to  a laundry  or  to  a dry  cleaning  estab- 
lishment. 

Dressing  jackets,  slippers,  etc.,  are  given  if  we  have 
them  on  hand. 


CLERICAL  WORK. 

Bulletin  Board.  All  changes  in  district,  class  and 
other  announcements  are  posted  on  a bulletin  board  in 
each  substation.  Every  communication  from  the  Main 
Office  marked  “Bulletin”  should  be  signed  by  initials 
of  each  nurse  reading  it.  The  bulletin  board  should  be 
read  daily  by  every  nurse  in  the  substation.  All  im- 
portant notices  are  posted  there.  Permanent  notices 
are  also  pasted  in  substation  bulletin  scrapbook. 

Call  Book.  A large  note  book  in  which  the  names 
and  addresses  of  all  new  patients  telephoned  into  the 
substation  are  written  daily.  The  number  of  the  dis- 
trict in  which  each  patient  lives  is  plainly  marked  in 
the  right-hand  column.  Each  nurse  is  expected  to  take 
her  own  calls  from  this  book  before  leaving  for  her 
afternoon  work.  When  taking  the  calls,  sign  initials 
to  each  call  in  checking  space,  thus -indicating  that  you 
have  copied  it  into  your  own  book,  and  then  sign  your 
name  at  the  bottom  of  the  page. 

The  call-book  is  also  the  daily  register  of  nurses’  at- 
tendance at  the  sub-station. 

Daily  Report  should  be  written  at  home  and  given 
daily  to  Supervisor  after  necessary  items  have  been 
transferred  from  it  to  time  book  and  records.  Hours 


80 


Visiting  Nurse  Manual 


on  duty  should  be  correctly  reported  (i.  e.,  8:00-5:00, 
8:30-7:30,  8:30-1:00,  8:30-4:30,  etc.). 

This  report  should  be  written  briefly,  but  every  item 
asked  is  important  and  should  be  recorded  when  pos- 
sible. Names  of  streets  should  not  be  abbreviated. 

Service  Money  (fees  from  patients)  may  be  given 
Supervisor  with  daily  report.  Amount,  date  received 
and  number  of  district  should  accompany  money.  Never 
credit  money  on  a daily  report  unless  it  has  been 
received  from  patient. 

Page-a-Day  Book  is  intended  for  convenience  of  each 
nurse,  may  be  written  in  pencil  and  destroyed  at  the 
end  of  the  year.  It  is  particularly  useful  for  record  of 
future  appointments  for  and  with  patients. 

Time  Book  is  a calendar  record  of  patients  seen  and 
calls  made  monthly.  It  is  kept  by  the  nurse  in  the 
district  and  serves  as  an  address  book,  a guide  to  the 
need  of  each  patient  for  frequent  or  infrequent  visits, 
and  a basis  for  the  monthly  statistical  report. 

The  district  boundaries  and  rules  for  keeping  time 
book  are  plainly  marked  on  the  cover  of  each.  Upon 
the  accuracy  of  every  time  book  depends  the  value  of 
the  annual  statistics  compiled  to  show  the  work  and 
growth  of  our  Association,  hence  the  importance  of  the 
slightest  detail  noted  in  this  book. 

Name  and  address  of  every  patient  visited  (even 
those  not  found)  should  be  entered  in  the  time  books. 

Calls  should  be  entered  under  proper  date.  Time 
book  should  be  written  daily,  the  calls  being  entered 
from  the  written  daily  report. 

Patients  Forwarded,  Transferred,  Dismissed,  Etc. 

All  cases  carried  in  time  book  for  more  than  one  visit 
require  diagnosis  and  physician’s  name. 

Every  forwarded  case  must  be  visited  monthly. 

Names  and  addresses  of  all  patients  to  be  dismissed 
to  other  public  health  nurses  (tuberculosis,  school,  etc.) 
should  be  handed  in  writing  to  the  Supervisor. 


Clerical  Work 


81 


Patients  transferred  from  other  districts  should  be 
entered  in  time  books  as  new  or  old,  as  date  indicates. 
The  total  calls  made  in  the  first  district  should  be  trans- 
ferred with  patient,  in  order  that  the  total  number  of 
calls  to  each  patient  may  be  forwarded  with  name  of 
patient.  The  calls  made  during-  current  month  should 
be  credited  to  the  district  in  which  they  were  made 
when  monthly  reports  are  being  compiled.  Thus  calls 
are  credited  to  the  district  in  which  they  were  made. 

Each  district  has  two  time  books  per  year,  used 
alternate  months.  The  one  not  being  carried  is  sent  to 
Main  Office  with  monthly  report,  and  both  are  checked 
by  filing  clerk. 

All  patients  forwarded  from  one  time  book  to  the 
other  are  classified  as  old  patients.  All  patients  taken 
on  the  books  between  8:30  a.  m.  of  the  26th  of  the 
month  and  5:00  p.  m.  of  the  25th  of  the  following  month 
are  new  cases. 

Monthly  Report.  Our  fiscal  month  closes  with  the 
25th  day  of  each  month  and  each  district  is  expected 
to  submit  a statistical  total  of  the  work  for  that  period. 
Our  statistics  are  compiled  by  districts.  One  or  more 
nurses  may  make  calls  in  a district  during  the  month, 
but  all  figures  are  credited  to  districts,  not  to  nurses. 
These  reports  should  be  given  the  Supervisors  not  later 
than  the  28th  of  each  month.  If  each  nurse,  in  pre- 
paring this  monthly  report,  is  careful  to  balance  the 
totals  properly,  a correct  report  will  be  submitted.  For 
statistical  purposes  an  incorrect  report  is  as  bad  as  an 
intentional  deception. 

Patient’s  Medical  Record  is  made  for  every  patient 
visited  more  than  three  times.  Daily  visits,  co-opera- 
tion asked  and  secured,  treatment  and  condition  of 
patient,  should  be  briefly  recorded.  Write  facts,  never 
opinions,  but  keep  the  history  of  the  case  in  such  a 
way  that  nurses  or  other  workers  using  that  card  later 
will  be  able  to  render  better  service  to  each  family 
because  of  your  help. 

Confidential.  No  record  card  nor  time  book  should 
ever  be  shown  in  a patient’s  home.  Make  notes  of 


82 


Visiting  Nurse  Manual 


figures,  dates,  etc.,  in  page-a-day  book  and  transfer 
to  records  m substations.  All  information  regarding 
cases  is  conridential  and  our  records  are  not  open  to 
inspection  unless  the  patient  may  be  directly  benefited 
by  this  exchange  of  information.  Commercial  houses, 
money  lenders,  etc.,  are  never  allowed  to  consult  our 
records,  buch  inquiries  should  always  be  referred  to 
the  Main  Office. 

When  dismissing,  review  case  mentally  and  make 
sure  that  your  work  is  completed.  Don't  waste  your 
care  and  effort  by  dismissing  a convalescent  too  soon 
or  by  neglecting  to  place  family  under  supervision  of 
the  proper  agency. 

Results,  not  numbers  of  visits  or  patients,  are  all 
that  count  in  our  work. 

Relief  Nurses.  A relief  nurse  is  any  nurse  making 
calls  in  other  districts.  A nurse  on  full  time  relief  worK 
maKes  any  calls  assigned  to  her,  but  a nurse 
in  a regular  district  frequently  makes  one  or  two  after- 
noon renei  calls  to  help  out  busier  districts  or  to  supply 
for  a half  day.  A relief  nurse  calling  on  old  patients 
should  write  a report  of  the  work  done  in  each  district 
entered  and  give  it  to  the  regular  nurse  the  following 
noon.  If  any  unusual  condition  is  found,  she  should 
report  that  evening  to  the  regular  nurse. 

A relief  nurse  making  a new  call  is  responsible  for 
the  “new  patient  data”  (name,  address,  sex,  age,  occu- 
pation, doctor,  diagnosis  and  by  whom  referred),  the 
M.  L.  report  card  data,  a telephoned  report  to  the  regu- 
lar nurse  that  evening,  and  a written  report  the  fol- 
lowing noon. 

A relief  nurse  should  know  the  home  telephone  of 
every  nurse  for  whom  she  makes  calls. 

A relief  nurse  is  responsible  for  the  new  calls  in 
the  district  in  which  she  relieves  during  the  regular 
nurse's  half  day. 

First  impressions  are  just  as  lasting  in  district  homes 
as  in  any  other  and  a relief  nurse  should  be  as  pains- 
taking and  attentive  in  another  district  as  she  would 
be  in  her  own. 


Clerical  Work 


83 


A relief  nurse  should  never  dismiss  a new  patient 
except  to  an  institution.  When  a first  call  has  been 
made  by  a relief  nurse,  the  regular  nurse  should  see 
the  patient  within  forty-eight  hours. 

Transfer.  A nurse  transferred  to  another  district 
should  give  her  time  book  to  her  Supervisor  and  should 
arrange  to  receive  the  calls  in  her  new  district  before 
the  next  morning. 


FAMILY  BUDGET, 


By  Florence  Nesbitt,  Field  Supervisor,  Funds  to  Parents’ 
Department,  Juvenile  Court  of  Cook  County. 

Normal  Standard  of  Living. 

An  income  of  at  least  $75.00  per  month  is  necessary 
to  maintain  a standard  of  living  which  will  insure  the 
health,  efficiency  and  moral  welfare  of  a family  con- 
sisting of  father,  mother  and  three  children  of 
school  age.  The  income  in  such  a family  should  be 
divided  among  the  different  items  of  expense  about  as 
follows: 


Monthly  Budget. 


1 Rent  $12.00 

2 Food  29.00 

3 Fuel,  light  and  ice 5.00 

4 Household  expenses 1.00 

5 Clothing  and  personal  expenses 13.00 

6 Carfare  2.50 

7 Insurance  2.00 

8 Furniture  2.50 

9 Education  1.00 

10  Care  of  health  (including  dental  work) 4.00 

11  Recreation  ’ 2.00 

12  Emergencies  1.00 


Total $75.00 


Adjustment  of  Lower  Incomes. 

A family  will  remain  self-supporting,  however,  on 
an  income  considerably  below  this  by  leaving  uncared 
for  the  last  four  items  on  the  budget,  or  by  relying  for 
them  upon  public  agencies  or  private  philanthropy. 

When  the  income  is  insufficient  to  cover  adequately 
the  first  eight  items  on  the  budget  the  standard  is 
necessarily  lowered  until  it  can  no  longer  be  considered 


Family  Budget 


85 


normal.  The  furniture  is  left  unrepaired,  the  clothing 
becomes  insufficient  or  is  provided  by  gifts,  ice  is  dis- 
pensed with,  fuel  is  gathered  from  neighboring  railroad 
tracks  or  torn-down  buildings.  Food  becomes  mono- 
tonous in  kind  and  barely  sufficient  in  quantity  to  meet 
the  fuel  requirement,  and  rent  is  reduced  by  living  in 
unwholesome  quarters.  By  any  or  all  of  these  means 
the  struggle  to  maintain  family  unity  and  self-respect 
may  be  prolonged. 

By  careful  consideration  of  the  income  and  the  needs 
of  the  family,  a nurse  will  be  able  to  determine  when 
gifts  or  relief  are  necessary  and  desirable.  She  will 
also  be  able  to  give  intelligent  advice  to  the  housewife 
to  help  her  guard  against  a disproportionately  large 
expenditure  for  any  of  the  items  of  the  budget.  Many 
mothers  are  failing  to  give  their  children  the  food  nec- 
essary for  proper  growth  and  development  in  order 
that  a rent  which  their  income  does  not  warrant  can 
be  paid,  or  that  a home  may  be  bought. 

Percentage  of  Income  Allowable  for  Rent. 

The  budget  above  allows  16  per  cent  of  the  income  to 
be  paid  for  rent  and  a higher  proportion  is  seldom 
advisable  in  families  belonging  to  the  low  income 
groups.  When  the  income  falls  below  the  amount  nec- 
essary to  cover  adequately  the  first  six  items  of 
the  budget,  the  rent  is  the  safest  item  to  reduce,  pro- 
vided that  light,  clean  rooms  of  sufficient  size  for  the 
family  can  be  secured  at  a lower  price  in  a neighbor- 
hood which  furnishes  good  advantages  for  the  work 
of  the  bread-winner  and  for  the  development  of  the 
children. 

Amount  Necessary  for  Food. 

The  housewife  can  make  a reduced  allowance  for  food 
cover  an  adequate,  well-balanced  diet  for  her  family 
only  by  the  most  careful  and  intelligent  management. 
The  problem  of  doing  this  would  prove  too  much  for 
many  graduates  of  schools  of  domestic  science,  yet  it 
is  constantly  forced  upon  women  who  not  only  are 
ignorant  of  food  values,  principles  of  economical  buy- 
ing and  sanitary  science,  but  who  also  are  untrained 


86 


Visiting  Nurse  Manual 


in  methodical  habits  of  thought  and  action.  Moreover, 
their  failure  to  solve  it  means  disease,  weakness  and 
inefficiency  for  the  families  for  whom  they  are  respon- 
sible. As  it  is  primarily  a question  of  health,  advice 
comes  most  naturally  from  the  nurse. 

Important  Things  About  Food  Which  Many  Mothers 
Do  Not  Know  Which  Visiting  Nurses 
May  Teach  Her. 

Coffee,  tea  and  other  stimulants  stunt  the  growth  of 
children,  pervert  their  taste  and,  wThen  used  in  excess, 
may  cause  cardiac  and  nephritis  complications. 

Food  habits  of  children  are  what  the  mother  makes 
them,  and  the  forming  of  these  habits  is  a serious  and 
most  important  part  of  her  work.  By  keeping  from 
them  stimulants,  highly  flavored  foods  and  excess  of 
sweets  they  may  be  led  to  like  cereals,  milk,  eggs, 
vegetables  and  fruit,  which  should  form  the  basis  of 
every  child’s  diet. 

Breakfast  is  a very  important  meal  for  school  chil- 
dren. Coffee  with  rolls  and  cake  is  insufficient  in  quan- 
tity and  unsuitable  in  kind.  Well  cooked  cereal  and 
milk  should  form  part  of  the  meal. 

Monotony  of  Diet  leads  to  anaemia,  undergrowth,  lack 
of  energy,  and  resistance  through  the  failure  to  provide 
proper  nourishment  to  the  body.  To  correct  this,  use 
whatever  vegetables  are  in  season  and  reasonable  in 
price,  and  as  much  fruit  as  can  be  afforded. 

Immigrant  parents  do  not  understand  our  various 
foods,  fruits  and  vegetables.  They  should  be  taught 
and  coaxed  to  try  other  food  preparations.  Strong 
American  citizens  cannot  be  raised  on  a Southern  Euro- 
pean diet  given  in  a northern  city,  nor  does  our  climate 
call  for  or  tolerate  a high  proteid  diet  such  as  English- 
men eat  constantly. 

COMPOSITION  OF  A CHEAP  DIETARY 

Cereals  (oatmeal,  cornmeal,  rice,  including  bread- 
stuffs)  must  furnish  a large  proportion  of  the  food  in  a 


Family  Budget 


87 


cheap  dietary,  as  they  are  the  foods  which  give  the 
greatest  amount  of  food  value  in  proportion  to  the  cost. 
They  should  be  used  in  as  large  a variety  as  possible 
to  avoid  monotony  of  diet.  Most  of  the  large  grocery 
stores  keep  several  kinds  of  cereals  in  bulk,  in  clean, 
well-covered  receptacles,  and  sell  them  at  a much  lower 
cost  than  the  same  cereal  in  packages.  A half  dozen 
or  more  equally  valuable  legumes  can  be  found  at 
most  of  these  stores,  and  should  be  used  instead  of 
always  using  navy  beans. 

The  cheaper  cuts  of  meat  must  be  used  and  these 
contain,  on  the  average,  as  much  nourishment  as  the 
more  expensive  ones.  Flavor  can  be  developed  in  these 
meats  and  tenderness  secured  by  proper  cooking. 

To  give  variety  to  the  diet  and  secure  mineral  bal- 
ance, fruits  and  vegetables  are  necessary.  Whatever 
articles  are  cheapest  at  the  time  must  be  used. 

Often  dried  fruits  or  root  vegetables  (beets,  carrots, 
turnips)  must  be  substituted  for  fresh.  These  can  be 
found  in  considerable  variety  at  large  stores. 

ECONOMY  IN  SELECTION  OF  FOOD  MATERIALS 

Among  the  foods  which  command  a high  price  in  pro- 
portion to  their  value  are: 

1.  Prepared  Foods. 

(a)  Cooked  Foods.  For  example,  bakery  bread, 
buns,  cakes,  pies,  etc.,  cost  from  two  to  three  time,s  as 
much,  exclusive  of  cost  of  fuel,  as  the  same  quality  of 
food  prepared  at  home. 

(b)  Canned  Foods.  For  example,  canned  soups, 
canned  baked  beans,  etc.,  cost  three  to  six  times  as 
much  as  the  raw  materials. 

Canned  vegetables  cost  about  twice  as  much  as  fresh 
vegetables,  and  do  not  fill  the  same  place  in  the  dietary. 
For  instance,  use  fresh  beets  or  carrots  instead  of 
canned  corn  or  peas. 

(c)  Prepared  Cereals.  Prepared  cereals  cost  three  to 
five  times  as  much  as  the  same  food  material  purchased 


88 


Visiting  Nurse  Manual 


raw  in  bulk.  For  example,  cornflakes  cost  about  four 
times  as  much  as  its  nutritive  equivalent  of  cornmeal. 

2.  Foods  Out  of  Season. 

When  foods  out  of  season  are  bought,  the  cost  of 
artificial  production  or  of  cold  storage  preservation 
must  usually  be  paid;  therefore,  in  late  spring,  apples 
will  cost  two  to  three  times  as  much  as  fresh  rhubarb. 
In  winter,  lettuce  will  cost  three  to  six  times  as  much 
as  turnips. 

3.  Foods  valued  for  flavor  are  expensive  in  propor- 
tion to  their  food  vaiue.  For  example,  fowl  cost  one 
and  one-half  to  three  times  as  much  as  its  nutritive 
equivalent  of  beef  or  mutton.  Butter  costs  almost 
twice  as  much  as  oleomargerine,  whose  food  value  is 
a little  higher. 

4.  Imported  Foods.  When  imported  foods  are 
bought,  the  cost  of  importation  must  be  paid  by  the 
purchaser;  therefore,  Italian  macaroni  costs  one  and 
one-fourth  times  as  much  as  the  best  American  brand 
and  imported  legumes  about  twice  as  much  as  native 
ones.  Imported  cheeses  cost  one  and  one-half  to  three 
times  as  much  as  American  and  are  only  slightly  higher 
in  food  value.  Foreign  people  would  profit  greatly  by 
learning  to  use  the  food  materials  of  their  adopted 
country. 

A fireless  cooker  can  be  made  for  50  cents  or  less  of 
a butter  tub,  with  asbestos,  crushed  paper  and  a covered 
pail.  Every  family  should  be  taught  to  prepare  cereals, 
slow-cooking  vegetables  and  meats  in  a cooker.  This 
will  save  much  in  fuel. 


INDEX 


(Wherever  a 

first  page  only  is  given.) 

Accidents  

Aged,  care  of 

Antidotes,  poison...... 

Baby.  See  Infant. 

Breast-feeding  42 

Burns  16,  46 

Calls  8,  76 

Cases  39,  70,  75 

Children  37,  62 

Chronics  61 

Clerical  work 79 

Communicable  diseases..34,  49 

Contagious  nursing 34,  49 

Convalescent  homes 37 

Co-operating  agencies 25 

Coroner  28,  31 

County  agent 31,  32,  34,  38 

County  physicians 34 

Death  31 

Diagnosis  18,  73 

Diet  55,  59,  86 

Disinfection  52,  56 

Dismissed  cases 39,  75 

Dispensaries  29,  36 

District  9 

Dressings  43 

Ears 17,  48 

Emergencies  28 

— housing  32 

— medical  28 

—relief  ; 32 

Eviction  32 

Eyes  47 

Family,  instruction  of 22 

Family  budget 84 

Family  physician 15 

Fees  and  gifts 23 

Food  32,  85 

Free  medical  service 33 

General  instructions 8 

Gifts  23 


Health  Department 

31,  32,  34,  38,  49,  52 

Home  conditions 74 

Hospital  service 34 

Housing  emergencies 32 

Illinois  Society  for  Mental 

Hygiene  38 

Industrial  nursing 75 

Infant  Welfare  Society 38 

Infants,  nursing  of....l6,  42,  64 

Infectious  diseases 16 

Insurance  and  industrial 
nursing  67 

Loan  closet 78 

Maternities 17,  29,  39,  68 

Medical  nursing 49 

Medical  relief 24 

Metropolitan  Life  Insurance 

Nursing  Service 23,  68 

Mid  wives  42 

Muni  c i p al  Tuberculosis 
Sanitarium  35 

New  calls 10,  76 

New  cases 70 

Nursing, 

— care  19 

— contagious 34,  49 

— medical  49 

— of  children 62 

— of  chronics 61 

— on  infants 64 

— surgical  43 

Nurses, 

—relief  82 

—special  24 

Obstretics.  See  Maternities. 
Ophthalmia  neonatorum 48 

Physicians 15,  33,  68,  75 

Poisons  30,  44 

Pregnancy.  See  Maternities. 

Private  hospitals 35 

Private  physicians 15 


reference  runs  over  more  than  one  page,  the 


28 

61 

30 


Visiting  Nurse  Manual 


90 


Records  70 

Registration  26 

Relief  24,  60 

— emergencies  32 

— medical  24 

— nurses  82 

Reports 75,  79,  81 

Sanitariums  35 

Special  nurses 24 

Standard  of  living 84 

Standing  orders 15 

Sterilization  52 

Substation  detail 77 

Summer  outings 38 


Supplies  

Surgical  nursing.... 

....12,  45,  77 
42 

Teeth  

Thermometers  .... 

Tuberculosis  

20 

14 

35,  56 

Uniforms  

12 

Ventilation  21 

Vermin  66 

Visiting  Nurse  Association, 
object  of 7 

Welfare  work 

76 

